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Service
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Cost
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Annual Deductible
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Group AIf you or your sponsor’s initial enlistment or appointment occurred before January 1, 2018, you are in Group A.:
- Individual: $150
- Family: $300
Group BIf you or your sponsor’s initial enlistment or appointment occurs on or after January 1, 2018, are in Group B.:
- Network:
- Individual: $150
- Family: $300
- Non-Network:
- Individual: $300
- Family: $600
Note: Non-active duty family members in Group B are subject to separate in-network and out-of-network deductibles. Reaching the deductible level of one does not remove the need to pay for the other.
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Ambulance Services
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Group A:
- Network: $98
- Non-Network: 25% of allowable charge
Group B:
- Network: $60
- Non-Network: 25% of allowable charge
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Ambulatory Surgery (Same Day)
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Group A:
Group B:
- Network: $95
- Non-Network: 25% of allowable charge
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Mental Health (Inpatient)
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See TRICARE Mental Health Costs
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Mental Health (Partial Hospitalization)
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See TRICARE Mental Health Costs
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Mental Health (Outpatient)
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See TRICARE Mental Health Costs
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Clinical Preventive Services
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Network:$0
Non-network: $0 for the following services:
- Cancer screenings* (colorectal, breast, cervical, prostate)
- Immunizations*
- Well-child care for children under age 6 (birth through age 5)
*This includes the office visit for beneficiaries age 6 and older when a covered cancer screening or immunization is provided during the visit.
For all other preventive services, non-network: 25% of allowable charge
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DME, Prosthetic Devices, Medical Supplies
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Network: 20% of negotiated fee
Non-Network: 25% of allowable charge
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Emergency Services
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Group A:
- Network: $109
- Non-Network: 25% of allowable charge
Group B:
- Network: $80
- Non-Network: 25% of allowable charge
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Home Health Care
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$0
Note: You may have separate costs for additional services when receiving home health care. For example, DME, drugs, vaccines, orthotics/prosthetics, and nutritional therapy, among others.
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Hospice Care
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$0
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Hospitalization (Inpatient Care)
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Group A:
- Network: 25% of allowable hospital charge ($250 per day maximum) plus 20% of allowable charge for separately billed services
- Non-Network: 25% of allowable hospital charge ($901 per day maximum) plus 25% of allowable charge for separately billed services
Group B:
- Network: $175 per admission
- Non-Network: 25% of allowable charge
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Immunizations
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$0
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Laboratory and X-ray
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Network: $0
Non-Network: 25% of allowable charge
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Maternity (office visits and hospitalization for delivery planned in a hospital in an inpatient setting)
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Group A:
- Network:
- 25% of allowable hospital charge ($250 per day maximum) plus 20% of allowable charge for separately billed services
- Non-Network:
- 25% of allowable hospital charge ($901 per day maximum) plus 25% of allowable charge for separately billed services
Group B:
- Network: $175 for hospital admission
- Non-Network: 25% of allowable charge
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Maternity (office visits for delivery planning in a TRICARE-authorized birthing center)
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Group A:
- Network: 20% of negotiated fee for delivery
- Non-Network: 25% of allowable charges
Group B:
- Network: $95 for delivery
- Non-Network: 25% of allowable charges
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Maternity (office visits for delivery planned at home or other setting)
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Group A:
- Network: $35 (Primary) or $45 (Specialty)
- Non-Network: 25% of allowable charge
Group B:
- Network: $25 (Primary) or $40 (Specialty)
- Non-Network: 25% of allowable charge
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Newborn Care
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Group A:
- Network:
- Days 1 - 3: $0
- Day 4+: 25% of allowable hospital charge ($250 per day maximum) plus 20% of allowable charge for separately billed services
- Non-Network:
- Days 1 - 3: $0
- Day 4+: 25% of allowable hospital charge ($250 per day maximum) plus 25% of allowable charge for separately billed services
Group B:
- Network: $0
- Non-Network: 25% of allowable charge
Note: If any family member is enrolled in TRICARE Prime, the newborn is also covered by Prime for up to the first 90 days and costs are $0.
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Outpatient Visit
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Group A:
- Network:
- Primary Care: $28
- Specialty Care: $41
- Non-Network: 25% of allowable charge
Group B:
- Network:
- Primary Care: $25
- Specialty Care: $40
- Non-Network: 25% of allowable charge
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Skilled Nursing (Inpatient)
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Group A:
- Network: 25% of allowable hospital charge ($250 per day maximum) plus 20% of allowable charge for separately billed services
- Non-Network: 25% of allowable charge
Group B:
- Network: $50 per day
- Non-Network: 20% of allowable charge ($300 per day maximum)
Only available in the U.S. and U.S. Territories.
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Urgent Care
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Group A:
- Network: $28
- Non-Network: 25% of allowable charge
Group B:
- Network: $40
- Non-Network: 25% of allowable charge
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