Cost Terms
Here are some definitions to help you better understand your costs with TRICARE.
| Term | Definition | Plans Where You’ll Find It | More Information |
|---|---|---|---|
| Allowable chargeThe maximum amount TRICARE pays for each procedure or service. This is tied by law to Medicare's allowable charges. |
The maximum amount TRICARE will pay a doctor or other provider for a procedure, service, or equipment. Non-participating providers can charge you up to 15% more than the allowable charge that TRICARE will pay. If you use a non-participating provider, you will have to pay all of that additional charge up to 15%. |
All TRICARE plans | TRICARE sets CHAMPUS Maximum Allowable Rate for most services. Many rates vary based on location, since health care costs more in some places and less in others. In some cases, federal law requires a set rate. You can find more information at Rates and Reimbursement. |
| Annual deductible | The amount you must pay before cost-sharing begins. |
TRICARE Select TRICARE Select Overseas TRICARE Reserve Select TRICARE Retired Reserve TRICARE Young Adult-Select option TRICARE For Life (for services not covered by both Medicare and TRICARE) If you have a TRICARE Prime plan, you have to meet your annual deductible when using the point-of-service option. |
TRICARE cost-sharing will begin when you meet your individual deductible. |
| Balance billing |
When a provider bills the difference between billed charges and what TRICARE, other health insuranceHealth insurance you have in addition to TRICARE, such as Medicare or an employer-sponsored health insurance. TRICARE supplements don’t qualify as "other health insurance.", and you paid. |
All TRICARE plans |
Network and participating providers can’t balance bill. By law, non-participating providers can only bill you up to 15% above the TRICARE-allowable charge. |
| Catastrophic cap | The most you pay out of pocket each year for TRICARE covered services. | All TRICARE plans |
Fees for covered services, including yearly (calendar year) enrollment fees, deductibles, copayments, pharmacy copayments, and other cost-shares based on TRICARE-allowable charges, apply toward your catastrophic cap. Point-of-service fees for TRICARE Prime don’t apply toward your catastrophic cap. For premium-based plans, your monthly premiums don’t apply toward your catastrophic cap. |
| copaymentA fixed dollar amount you may pay for a covered health care service or drug. | The fixed dollar amount you pay for a covered healthcare service or drug. |
TRICARE Prime and TRICARE Prime Remote (Doesn’t apply to active duty service members) TRICARE Select for services received from network providers |
A copayment for an appointment also covers your costs for tests and other ancillary services you get as part of that appointment. So if your doctor runs blood work as part of your visit, or you have an EKG or other test covered by TRICARE, you normally won’t have a separate copayment for those tests. |
| cost-shareA percentage of the total cost of a covered health care service that you pay. | The percentage of the total cost of a covered healthcare service that you pay. |
All TRICARE Plans (Doesn’t apply to active duty service members) |
If you see several doctors as part of an appointment or have additional tests, you may have more than one cost-share. For instance, if you have a surgery, you may have separate cost-shares for the facility, the surgeon, and the anesthesiologist. |
| Negotiated rate | The contractors who manage care in the civilian network try to save you and the government money by making agreements with providers to accept less than the allowable charge for your care. |
All TRICARE Plans (Doesn’t apply to active duty service members) |
Since some plans have cost-shares that are a percentage of the charge, a lower rate helps keep your costs down. That’s why it’s usually less expensive for you to use a network provider for your care. |
| Point-of-service fees |
The fees you pay when you see a TRICARE-authorized providerAn authorized provider is any individual, institution/organization, or supplier that is licensed by a state, accredited by national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE. There are two types of TRICARE-authorized providers: Network and Non-Network. DS other than your primary care manager for any nonemergency care without a referral. The costs are higher when you don’t follow referral requirements or use non-network providers without authorization from the TRICARE regional contractor. |
TRICARE Prime (Doesn’t apply to active duty service members) |
You pay an annual deductible before TRICARE cost-sharing begins. The deductibles are $300 per individual/$600 per family. For services beyond this deductible, you pay 50% of the TRICARE-allowable charge. These costs don’t apply to your catastrophic cap. |
| Travel expensesAmounts you pay when traveling to and from your appointment. This includes mileage, meals, tolls, parking, lodging, local transportation, and tickets for public transportation. | The amount you pay when traveling to and from your appointment. This includes costs for gas, meals, tolls, parking, lodging, local transportation, and tickets for public transportation. |
TRICARE Prime TRICARE Prime Remote TRICARE For Life Prime Travel Benefit |
In some instances, TRICARE may reimburse your travel expenses for care. To receive reimbursement for travel expenses for specialty careSpecialized medical/surgical diagnosis, treatment, or services a primary care provider isn’t qualified to provide.:
If all three apply to you, you may qualify for the Prime Travel Benefit. |
| TRICARE diagnostic-related group (DRG) | A payment system that determines the allowable amount. | TRICARE Select | Learn more about DRG rates. |
Last Updated 11/21/2024
