Health Plan Costs

TRICARE Prime & TRICARE Select Group A

Costs for active duty family members and transitional survivors

Active duty service members don’t have out-of-pocket costs.
“Network” means a provider in the TRICARE network. “Non-network” means a TRICARE-authorized provider not in the TRICARE network.
Cost-shares are percentages of the TRICARE maximum-allowable charge after the annual deductible is met.

Cost Type	TRICARE Prime—Group A	TRICARE Select—Group A
Enrollment Fee (Annual)	$0	$0
Deductible (Annual)	$0	E-1 through E-4: $50 per individual $100 per family E-5 & above: $150 per individual $300 per family
Catastrophic Cap (Annual)	$1,000 per family	$1,000 per family
Clinical Preventive Services	Network: $0 Non-network: Point-of-service fees	Network and Non-network: $0
Outpatient Visit—Primary	Network: $0 Non-network: Point-of-service fees	Network: $28 Non-network: 20%
Outpatient Visit—Specialty	Network: $0 Non-network: Point-of-service fees	Network: $39 Non-network: 20%
Urgent Care	Network provider or TRICARE-authorized urgent care center: $0 Any other urgent care provider: Point-of-service fees	Network: $28 Non-network: 20%
Emergency Visit	Network or Non-network: $0	Network: $103 Non-network: 20%
Laboratory and X-ray	Network: $0 Non-network: Point-of-service fees	Network: $0 Non-network: 20%
Ambulatory Surgery	Network: $0 Non-network: Point-of-service fees	Network and Non-network: $25
Ambulance	Network: $0 Non-network: Point-of-service fees	Outpatient (Ground): Network: $88; Non-network: 20% Outpatient (Air): 20% (Network or Non-network) Inpatient: 20%
Mental Health (Inpatient)	Network: $0 Non-network: Point-of-service fees	Network and Non-network: $24.50 per day or $25 per admission (whichever is more)
Mental Health (Outpatient/Partial Hospitalization)—Specialty Care	Network: $0 Non-network: Point-of-service fees	Network: $39 Non-network: 20%
Mental Health (Residential Treatment Facility)	Network: $0 Non-network: Point-of-service fees	Network and Non-network: $24.50 per day or $25 per admission (whichever is more)
Durable Medical Equipment	Network: $0 Non-network: Point-of-service fees	Network: 15% Non-network: 20%
Home Health Care	Network: $0 Non-network: Point-of-service fees	Network: $0
Hospice Care	Network: $0 Non-network: Point-of-service fees	Network: $0 (Medical equipment and pharmacy are billed separately.)
Hospitalization (Inpatient Care)	Network: $0 Non-network: Point-of-service fees	Network and Non-network: $24.50 per day or $25 per admission (whichever is more)
Maternity (Delivery/Inpatient)	Network: $0 Non-network: Point-of-service fees	Network and Non-network: $24.50 per day or $25 per admission (whichever is more)
Maternity (Delivery/Birthing Center)	Network: $0 Non-network: Point-of-service fees	Network and Non-network: $25
Maternity (Home)—Primary	Network: $0 Non-network: Point-of-service fees	Network: $28 Non-network: 20%
Maternity (Home)—Specialty	Network: $0 Non-network: Point-of-service fees	Network: $39 Non-network: 20%
Newborn Care	Network: $0 Non-network: Point-of-service fees	Network and Non-network: $0
Inpatient Skilled Nursing Facility/Rehab Facility	Network: $0 Non-network: Point-of-service fees	Network and Non-network: $24.50 per day or $25 per admission (whichever is more)

TRICARE Prime & TRICARE Select Group B

Costs for active duty family members and transitional survivors

Active duty service members don’t have out-of-pocket costs.
“Network” means a provider in the TRICARE network. “Non-network” means a TRICARE-authorized provider not in the TRICARE network.
Cost-shares are percentages of the TRICARE maximum-allowable charge after the annual deductible is met.

Cost Type	TRICARE Prime—Group B	TRICARE Select—Group B
Enrollment Fees (Annual)	$0	$0
Deductible (Annual)	$0	E-1 through E-4: $66 per individual $132 per family E-5 & above: $198 per individual $397 per family
Catastrophic Cap (Annual)	$1,324 per family	$1,324 per family
Clinical Preventive Services	Network: $0 Non-network: Point-of-service fees	Network and non-network: $0
Outpatient Visit—Primary Care	Network: $0 Non-network: Point-of-service fees	Network: $19 Non-network: 20%
Outpatient Visit—Specialty Care	Network: $0 Non-network: Point-of-service fees	Network: $33 Non-network: 20%
Urgent Care	Network provider or TRICARE-authorized urgent care center: $0 Any other urgent care provider: Point-of-service fees	Network: $26 Non-network: 20%
Emergency Visit	Network or Non-network: $0	Network: $52 Non-network: 20%
Laboratory and X-ray	Network: $0 Non-network: Point-of-service fees	Network: $0 Non-network: 20%
Ambulatory Surgery	Network: $0 Non-network: Point-of-service fees	Network: $33 Non-network: 20%
Ambulance	Network: $0 Non-network: Point-of-service fees	Outpatient (Ground): Network: $19; Non-network: 20% Outpatient (Air): 20% (Network or Non-network) Inpatient: 20%
Mental Health (Inpatient)	Network: $0 Non-network: Point-of-service fees	Network: $79 per admission Non-network: 20%
Mental Health (Outpatient/Partial Hospitalization)—Specialty Care	Network: $0 Non-network: Point-of-service fees	Network: $33 Non-network: 20%
Mental Health (Residential Treatment Facility)	Network: $0 Non-network: Point-of-service fees	Network: $33 per admission Non-network: $66 per admission
Durable Medical Equipment	Network: $0 Non-network: Point-of-service fees	Network: 10% Non-network: 20%
Home Health Care	Network: $0 Non-network: Point-of-service fees	Network: $0
Hospice Care	Network: $0 Non-network: Point-of-service fees	Network: $0 (Medical equipment and pharmacy are billed separately.)
Hospitalization (Inpatient Care)	Network: $0 Non-network: Point-of-service fees	Network: $79 per admission Non-network: 20%
Maternity (Delivery/Inpatient)	Network: $0 Non-network: Point-of-service fees	Network: $79 per admission Non-network: 20%
Maternity (Delivery/Birthing Center)	Network: $0 Non-network: Point-of-service fees	Network: $33 Non-network: 20%
Maternity (Home)—Primary Care	Network: $0 Non-network: Point-of-service fees	Network: $19 Non-network: 20%
Maternity (Home)—Specialty Care	Network: $0 Non-network: Point-of-service fees	Network: $33 Non-network: 20%
Newborn Care	Network: $0 Non-network: Point-of-service fees	Network: $0 Non-network: 20%
Inpatient Skilled Nursing Facility/Rehab Facility	Network: $0 Non-network: Point-of-service fees	Network: $33 per admission Non-network: $66 per admission

TRICARE Prime & TRICARE Select Group A

Costs for all retirees, their family members, survivors, and others

“Network” means a provider in the TRICARE network. “Non-network” means a TRICARE-authorized provider not in the TRICARE network.
Cost-shares are percentages of the TRICARE maximum-allowable charge after the annual deductible is met.

Cost Type	TRICARE Prime—Group A	TRICARE Select—Group A
Enrollment Fee (Annual)	Individual: $381.96 Family: $765 Medically retired sponsors, their family members, and survivors: See the table below for your enrollment fee.	Individual: $186.96 Family: $375 Individual & Family: $0 for medically retired sponsors, their family members, and survivors
Deductible (Annual)	$0	Individual: $150 Family: $300
Catastrophic Cap (Annual)	$3,000 per family	$4,381 per family $3,000 per family for medically retired sponsors, their family members, and survivors
Clinical Preventive Services	$0	$0
Outpatient Visit—Primary Care	Network: $26 Non-network: Point-of-service fees	Network: $38 Non-network: 25%
Outpatient Visit—Specialty Care	Network: $39 Non-network: Point-of-service fees	Network: $52 Non-network: 25%
Urgent Care	Network provider or TRICARE-authorized urgent care center: $39 Any other urgent care provider: Point-of-service fees	Network: $38 Non-network: 25%
Emergency Visit	Network or Non-network: $79	Network: $138 Non-network: 25%
Laboratory and X-ray	Network: $0 Non-network: Point-of-service fees	Network: $0 Non-network: 25%
Ambulatory Surgery	Network: $79 Non-network: Point-of-service fees	Network: 20% Non-network: 25%
Ambulance	Outpatient (Ground): $52 Outpatient (Air): $20 Inpatient: 25%	Outpatient (Ground): Network: $117; Non-network: 25% Outpatient (Air): 25% (Network or Non-network) Inpatient: 25%
Mental Health (Inpatient)	Network: $198 per admission Non-network: Point-of-service fees	Network: $250 per day or up to 25% of hospital charges (whichever is less), plus 20% of separately billed services Non-network: $1,306 per day* or up to of 25% hospital charge (whichever is less), plus 25% of separately billed services
Mental Health (Outpatient/Partial Hospitalization)—Specialty Care	Network: $39 Non-network: Point-of-service fees	Network: $52 Non-network: 25%
Mental Health (Residential Treatment Facility)	Network: $39 per day Non-network: Point-of-service fees	Network: $250 per day or up to 25% of hospital charges (whichever is less), plus 20% of separately billed services Non-network: 25%
Durable Medical Equipment	Network: 20% Non-network: Point-of-service fees	Network: 20% Non-network: 25%
Home Health Care	Network: $0 Non-network: Point-of-service fees	Network: $0
Hospice Care	Network: $0 (Medical equipment and pharmacy are billed separately.)	Network: $0 (Medical equipment and pharmacy are billed separately.)
Hospitalization (Inpatient Care)	Network: $198 per admission Non-network: $198 per admission	Network: $250 per day or up to 25% of hospital charges (whichever is less), plus 20% of separately billed services Non-network: $1,306 per day* or up to 25% of hospital charges (whichever is less), plus 25% of separately billed services
Maternity (Delivery/Inpatient)	Network: $198 per admission	Network: $250 per day or up to 25% of hospital charges (whichever is less), plus 20% of separately billed services Non-network: $1,306 per day* or up to 25% of hospital charges (whichever is less), plus 25% of separately billed services
Maternity (Delivery/Birthing Center)	Network: $79 Non-network: Point-of-service fees	Network: 20% Non-network: 25%
Maternity (Home)—Primary Care	Network: $26 Non-network: Point-of-service fees	Network: $38 Non-network: 25%
Maternity (Home)—Specialty Care	Network: $39 Non-network: Point-of-service fees	Network: $52 Non-network: 25%
Newborn Care	Network: $0 Non-network: Point-of-service fees	$0
Inpatient Skilled Nursing Facility/Rehab Facility	Network: $39 per day Non-network: Point-of-service fees	Network: $250 per day or up to 25% of hospital charges (whichever is less), plus 20% of separately billed services Non-network: 25%

*Cost through Dec. 31, 2025. All final claims reimbursed under the TRICARE Diagnosis Related Group-based payment system are to be priced using the rules, weights, and rates in effect as of the date of discharge.

TRICARE Prime enrollment fee for medically retired sponsors, their family members, and survivors in Group A

Your enrollment fee freezes at the rate when you were classified in DEERS as medically retired or as a survivor and enrolled in TRICARE Prime. It stays frozen as long as there is no break in your TRICARE Prime enrollment.

Date of Classification in DEERS	Annual Enrollment Fee
Starting Jan. 1, 2026	Individual: $381.96 Family: $765
Between Jan. 1, 2024 and Dec. 31, 2025	Individual: $372 Family: $744
Between Jan. 1, 2024 and Dec. 31, 2024	Individual: $363 Family: $726
Between Jan. 1, 2023 and Dec. 31, 2023	Individual: $351.96 Family: $703.92
Between Jan. 1, 2022 and Dec. 31, 2022	Individual: $323 Family: $647
Between Jan. 1, 2021 and Dec. 31, 2021	Individual: $303 Family: $606
Between Jan. 1, 2020 and Dec. 31, 2020	Individual: $300 Family: $600
Between Jan. 1, 2019 and Dec. 31, 2019	Individual: $297 Family: $594
Between Jan. 1, 2018 and Dec. 31, 2018	Individual: $289.08 Family: $578.16
Between Oct. 1, 2015 and Dec. 31, 2017	Individual: $282.60 Family: $565.20
Between Oct. 1, 2014 and Sept. 30, 2015	Individual: $277.92 Family: $555.84
Between Oct. 1, 2013 and Sept. 30, 2014	Individual: $273.84 Family: $547.68
Between Oct. 1, 2012 and Sept. 30, 2013	Individual: $269.28 Family: $538.56
Between Oct. 1, 2011 and Sept. 30, 2012	Individual: $260 Family: $520
Before Oct. 1, 2011	Individual: $230 Family: $460

TRICARE Prime & TRICARE Select Group B

Costs for retirees, their family members, survivors, and others

“Network” means a provider in the TRICARE network. “Non-network” means a TRICARE-authorized provider not in the TRICARE network.
Cost-shares are percentages of the TRICARE maximum-allowable charge after the annual deductible is met.

Cost Type	TRICARE Prime—Group B	TRICARE Select—Group B
Enrollment Fee (Annual)	$462.96 per individual $927 per family	$594.96 per individual $1,191 per family
Deductible (Annual)	$0	Individual $198 (Network) $397 (Non-network) Family $397 (Network) $794 (Non-network) Note: Prescription costs also apply to your annual deductible.
Catastrophic Cap (Annual)	$4,635 per family	$4,635 per family
Clinical Preventive Services	$0	$0
Outpatient Visit—Primary Care	Network: $26 Non-network: Point-of-service fees	Network: $33 Non-network: 25%
Outpatient Visit—Specialty Care	Network: $39 Non-network: Point-of-service fees	Network: $52 Non-network: 25%
Urgent Care	Network provider or TRICARE-authorized urgent care center: $39 Any other urgent care provider: Point-of-service fees	Network: $52 Non-network: 25%
Emergency Visit	Network or Non-network: $79	Network: $105 Non-network: 25%
Laboratory & X-ray	Network: $0 Non-network: Point-of-service fees	Network: $0 Non-network: 25%
Ambulatory Surgery	Network: $79 Non-network: Point-of-service fees	Network: $125 Non-network: 25%
Ambulance	Outpatient (Ground): $52 Outpatient (Air): $20 Inpatient: 25%	Outpatient (Ground): Network: $79; Non-network: 25% Outpatient (Air): 25% (network or non-network) Inpatient: 25%
Mental Health (Inpatient)	Network: $198 per admission Non-network: Point-of-service fees	Network: $231 per admission Non-Network: 25%
Mental Health (Outpatient/Partial Hospitalization)—Specialty Care	Network: $39 Non-network: Point-of-service fees	Network: $52 Non-network: 25%
Mental Health (Residential Treatment Facility)	Network: $39 Non-network: Point-of-service fees	Network: $66 per day Non-network: $397 per day or 20% (whichever is less)
Durable Medical Equipment	Network: 20% Non-network: Point-of-service fees	Network: 20% Non-network: 25%
Home Health Care	Network: $0 Non-network: Point-of-service fees	Network: $0
Hospice Care	Network: $0 (Medical equipment and pharmacy are billed separately.) Non-network: Point-of-service fees	Network: $0 (Medical equipment and pharmacy are billed separately.)
Hospitalization (Inpatient Care)	Network: $198 per admission Non-network: $198 per admission	Network: $231 per admission Non-network: 25%
Maternity (Delivery/Inpatient)	Network: $198 per admission	Network: $231 per admission Non-network: 25%
Maternity (Delivery/Birthing Center)	Network: $79 Non-network: Point-of-service fees	Network: $125 per admission Non-network: 25%
Maternity (Home)—Primary Care	Network: $26 Non-network: Point-of-service fees	Network: $33 Non-network: 25%
Maternity (Home)—Specialty Care	Network: $39 Non-network: Point-of-service fees	Network: $52 Non-network: 25%
Newborn Care	Network: $0 Non-network: Point-of-service fees	Network: $0 Non-network: 20%
Inpatient Skilled Nursing Facility/Rehab Facility	Network: $39 per day Non-network: Point-of-service fees	Network: $66 per day Non-network: $397 per day or 20% (whichever is less)

TRICARE For Life

Check out the TRICARE For Life Cost Matrix. This fact sheet shows what Medicare pays for services covered by Medicare and TRICARE.

TRICARE Reserve Select

“Network” means a provider in the TRICARE network. “Non-network” means a TRICARE-authorized provider not in the TRICARE network.
Cost-shares are percentages of the TRICARE maximum-allowable charge after the annual deductible is met.

Cost Type	TRICARE Reserve Select
Premium (Monthly)	Member only: $57.88 Member and family: $286.66
Deductible (Annual)	E-1 through E-4: $66 per individual $132 per family E-5 & above: $198 per individual $397 per family Note: Prescription costs also apply to your annual deductible.
Catastrophic Cap (Annual)	$1,324 per family
Clinical Preventive Services	$0
Outpatient Visit—Primary Care	Network: $19 Non-network: 20%
Outpatient Visit—Specialty Care	Network: $33 Non-network: 20%
Urgent Care	Network: $26 Non-network: 20%
Emergency Visit	Network: $52 Non-network: 20%
Laboratory & X-ray	Network: $0 Non-network: 25%
Ambulatory Surgery	Network: $33 Non-network: 20%
Ambulance	Outpatient (Ground): Network: $19; Non-network: 20% Outpatient (Air): 20% (network or non-network) Inpatient: 25%
Mental Health (Inpatient)	Network: $79 per admission Non-network: 20%
Mental Health (Outpatient/Partial Hospitalization)—Specialty Care	Network: $33 Non-network: 20%
Mental Health (Residential Treatment Facility)	Network: $33 per day Non-network: $66 per day
Durable Medical Equipment	Network: 10% Non-network: 20%
Home Health Care	Network: $0
Hospice Care	Network: $0 (Medical equipment and pharmacy are billed separately.)
Hospitalization (Inpatient Care)	Network: $79 per admission Non-network: 20%
Maternity (Delivery/Inpatient)	Network: $79 per admission Non-network: 20%
Maternity (Delivery/Birthing Center)	Network: $33 per admission Non-network: 20%
Maternity (Home)—Primary Care	Network: $19 Non-network: 20%
Maternity (Home)—Specialty Care	Network: $33 Non-network: 20%
Newborn Care	Network: $0 Non-network: 20%
Inpatient Skilled Nursing Facility/Rehab Facility	Network: $33 per day Non-network: $66 per day

TRICARE Retired Reserve

“Network” means a provider in the TRICARE network. “Non-network” means a TRICARE-authorized provider not in the TRICARE network.
Cost-shares are percentages of the TRICARE maximum-allowable charge after the annual deductible is met.

Cost Type	TRICARE Retired Reserve
Premium (Monthly)	Member only: $645.90 Member and family: $1,548.30
Deductible (Annual)	Network: $198 per individual $397 per family Non-network: $397 per individual $794 per family Note: Prescription costs also apply to your annual deductible.
Catastrophic Cap (Annual)	$4,635 per family
Clinical Preventive Services	$0
Outpatient Visit—Primary Care	Network: $33 Non-network: 25%
Outpatient Visit—Specialty Care	Network: $52 Non-network: 25%
Urgent Care	Network: $52 Non-network: 25%
Emergency Visit	Network: $105 Non-network: 25%
Laboratory & X-ray	Network: $0 Non-network: 25%
Ambulatory Surgery	Network: $125 Non-network: 25%
Ambulance	Outpatient (Ground): Network: $79; Non-network: 25% Outpatient (Air): 25% (network or non-network) Inpatient: 25%
Mental Health (Inpatient)	Network: $231 per admission Non-network: 25%
Mental Health (Outpatient/Partial Hospitalization)—Specialty Care	Network: $52 Non-network: 25%
Mental Health (Residential Treatment Center)	Network: $66 per day Non-network: $397 per day or 20% (whichever is less)
Durable Medical Equipment	Network: 20% Non-network: 25%
Home Health Care	Network: $0
Hospice Care	Network: $0 (Medical equipment and pharmacy are billed separately.)
Hospitalization (Inpatient Care)	Network: $231 per admission Non-network: 25%
Maternity (Delivery/Inpatient)	Network: $231 per admission Non-network: 25%
Maternity (Delivery/Birthing Center)	Network: $125 per admission Non-network: 25%
Maternity (Home)—Primary Care	Network: $33 Non-network: 25%
Maternity (Home)—Specialty Care	Network: $52 Non-network: 25%
Newborn Care	Network: $0 Non-network: 20%
Inpatient Skilled Nursing Facility/Rehab Facility	Network: $66 per day Non-network: $397 per day or 20% (whichever is less)

TRICARE Young Adult

Except for monthly premiums, all TRICARE Young Adult costs follow Group B costs, based on your plan option and sponsor’s status.
“Network” means a provider in the TRICARE network. “Non-network” means a TRICARE-authorized provider not in the TRICARE network.
Cost-shares are percentages of the TRICARE maximum-allowable charge after the annual deductible is met.

Costs for adult children of active duty sponsors and TRICARE Reserve Select enrollees

Cost Type	TRICARE Young Adult-Prime Sponsor status: Active duty	TRICARE Young Adult-Select Sponsor status: Active duty or TRS enrollee
Premium (Monthly)	$794 per individual	$363 per individual
Deductible (Annual)	$0	E-1 through E-4: $66 per individual E-5 & above: $198 per individual Note: Prescription costs also apply to your annual deductible.
Catastrophic Cap (Annual)	$1,324 per family	$1,324 per family
Clinical Preventive Services	Network: $0 Non-network: Point-of-service fees	$0
Outpatient Visit—Primary Care	Network: $0 Non-network: Point-of-service fees	Network: $19 Non-network: 20%
Outpatient Visit—Specialty Care	Network: $0 Non-network: Point-of-service fees	Network: $33 Non-network: 20%
Urgent Care	Network provider or TRICARE-authorized urgent care center: $0 Any other urgent care provider: Point-of-service fees	Network: $26 Non-network: 20%
Emergency Visit	Network or Non-network: $0	Network: $52 Non-network: 20%
Laboratory & X-ray	Network: $0 Non-network: Point-of-service fees	Network: $0 Non-network: 20%
Ambulatory Surgery	Network: $0 Non-network: Point-of-service fees	Network: $33 Non-network: 20%
Ambulance	Network: $0 Non-network: Point-of-service fees	Outpatient (Ground): Network: $19; Non-network: 20% Outpatient (Air): 20% network or non-network Inpatient: 20%
Mental Health (Inpatient)	Network: $0 Non-network: Point-of-service fees	Network: $79 per admission Non-network: 20%
Mental Health (Outpatient/Partial Hospitalization)—Specialty Care	Network: $0 Non-network: Point-of-service fees	Network: $33 Non-network: 20%
Mental Health (Residential Treatment Facility)	Network: $0 Non-network: Point-of-service fees	Network: $33 per day Non-network: $66 per day
Durable Medical Equipment	Network: $0 Non-network: Point-of-service fees	Network: 10% Non-network: 20%
Home Health Care	Network: $0 Non-network: Point-of-service fees	Network: $0
Hospice Care	Network: $0 Non-network: Point-of-service fees	Network: $0 (Medical equipment and pharmacy are billed separately.)
Hospitalization (Inpatient Care)	Network: $0 Non-network: Point-of-service fees	Network: $79 per admission Non-network: 20%
Maternity (Delivery/Inpatient)	Network: $0 Non-network: Point-of-service fees	Network: $79 per admission Non-network: 20%
Maternity (Delivery/Birthing Center)	Network: $0 Non-network: Point-of-service fees	Network: $33 per admission Non-network: 20%
Maternity (Home)—Primary Care	Network: $0 Non-network: Point-of-service fees	Network: $19 Non-network: 20%
Maternity (Home)—Specialty Care	Network: $0 Non-network: Point-of-service fees	Network: $33 Non-network: 20%
Inpatient Skilled Nursing Facility/Rehab Facility	Network: $0 Non-network: Point-of-service fees	Network: $33 per day Non-network: $66 per day

Costs for adult children of retired sponsors and TRICARE Retired Reserve enrollees

Cost Type	TRICARE Young Adult-Prime Sponsor status: Retired	TRICARE Young Adult-Select Sponsor status: Retired or TRR enrollee
Premium (Monthly)	$794 per individual	$363 per individual
Deductible (Annual)	$0	Network: $198 per individual Non-network: $397 per individual Note: Prescription costs also apply to your annual deductible.
Catastrophic Cap (Annual)	$4,635 per family	$4,635 per family
Clinical Preventive Services	Network: $0 Non-network: Point-of-service fees	$0
Outpatient Visit—Primary Care	Network: $26 Non-network: Point-of-service fees	Network: $33 Non-network: 25%
Outpatient Visit—Specialty Care	Network: $39 Non-network: Point-of-service fees	Network: $52 Non-network: 25%
Urgent Care	Network provider or TRICARE-authorized urgent care center: $39 Any other urgent care provider: Point-of-service fees	Network: $52 Non-network: 25%
Emergency Visit	Network or Non-network: $79	Network: $105 Non-network: 25%
Laboratory & X-ray	Network: $0 Non-network: Point-of-service fees	Network: $0 Non-network: 25%
Ambulatory Surgery	Network: $79 Non-network: Point-of-service fees	Network: $125 Non-network: 25%
Ambulance	Outpatient (Ground): $52 Outpatient (Air): $20 Inpatient: 25% of allowable charge	Outpatient (Ground): Network: $79 Non-network: 25% Outpatient (Air): 25% network or non-network Inpatient: 25% of allowable charge
Mental Health (Inpatient)	Network: $198 per admission Non-network: Point-of-service fees	Network: $231 per admission Non-network: 25%
Mental Health (Outpatient/Partial Hospitalization)—Specialty Care	Network: $39 Non-network: Point-of-service fees	Network: $52 Non-network: 25%
Mental Health (Residential Treatment Facility)	Network: $39 per day Non-network: Point-of-service fees	Network: $66 per day Non-network: $397 per day or 20% (whichever is less)
Durable Medical Equipment	Network: 20% Non-network: Point-of-service fees	Network: 20% Non-network: 25%
Home Health Care	Network: $0 Non-network: Point-of-service fees	Network: $0
Hospice Care	Network: $0 (Medical equipment and pharmacy are billed separately.) Non-network: Point-of-service fees	Network: $0 (Medical equipment and pharmacy are billed separately.)
Hospitalization (Inpatient Care)	Network: $198 per admission Non-network: $198 per admission	Network: $231 per admission Non-network: 25%
Maternity (Delivery/Inpatient)	Network: $198 per admission	Network: $231 per admission Non-network: 25%
Maternity (Delivery/Birthing Center)	Network: $79 Non-network: Point-of-service fees	Network: $125 per admission Non-network: 25%
Maternity (Home)—Primary Care	Network: $26 Non-network: Point-of-service fees	Network: $33 Non-network: 25%
Maternity (Home)—Specialty Care	Network: $39 Non-network: Point-of-service fees	Network: $52 Non-network: 25%
Inpatient Skilled Nursing Facility/Rehab Facility	Network: $39 per day Non-network: Point-of-service fees	Network: $66 per day Non-network: $397 per day or 20% (whichever is less)