Know Your Costs Before Making a Choice During TRICARE Open Season
Active duty service members (ADSMs) are required to have TRICARE Prime health coverage. Active duty family members (ADFMs), retirees, and eligible retiree family members can choose to have either TRICARE Prime or TRICARE Select coverage.
For many people, cost is a major factor in picking a health care plan. Before you choose a plan, make sure you know what’s covered and what it costs. To help you understand your potential health care costs, here are a few key TRICARE terms you should know.
- TRICARE beneficiaries fall into one of two groups: Group AClick to closeIf you or your sponsor’s initial enlistment or appointment occurred before January 1, 2018, you are in Group A. or Group BClick to closeIf you or your sponsor’s initial enlistment or appointment occurs on or after January 1, 2018, are in Group B.. Each group has different enrollment fees, deductibles, and out-of-pocket costs. You’re in Group A if your initial enlistment or appointment or that of your uniformed services sponsor began before Jan. 1, 2018. You’re in Group B if your initial enlistment or appointment or that of your uniformed services sponsor began on or after Jan. 1, 2018. When enrolled in TRICARE Reserve Select, TRICARE Retired Reserve, TRICARE Young Adult, or Continued Health Care Benefit Program follow Group B deductibles, copayments, cost-shares, and catastrophic caps regardless of when the uniformed services sponsor enlisted or was appointed.
- An enrollment fee is the yearly amount you pay to enroll in TRICARE Prime or TRICARE Select. ADSMs and ADFMs don’t have an enrollment fee with TRICARE Prime. However, TRICARE Prime retirees, their families, and some others pay yearly enrollment fees. With TRICARE Select, ADFMs don’t pay enrollment fees, and neither do Group A retirees, their families, and others with TRICARE Select. However, Group B retirees, their families, and others pay yearly enrollment fees. Visit Health Plan Costs for more information.
- A deductible is a fixed amount you pay for covered services each calendar year before TRICARE pays anything. You may have a deductible if you have TRICARE Select or if you have TRICARE Prime but see a provider without a referral.
- A cost-share is a percentage of the total cost of a covered health care service that you pay after you pay your deductible.
- A copaymentClick to closeA fixed dollar amount you may pay for a covered health care service or drug. is the fixed amount those with TRICARE Prime (who aren’t active duty) and TRICARE Select (for certain services) pay for a covered health care service or drug.
- The catastrophic cap is the most you or your family will pay out of pocket for covered health care services each calendar year. When met, TRICARE pays your copayment or cost-share for covered health care services for the rest of the calendar year.
- Point-of-service is an option under TRICARE Prime where you pay extra when getting nonemergency care from any TRICARE-authorized providerClick to closeAn 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. without a referral. The point-of-service option isn’t available to ADSMs.
- The TRICARE-allowable chargeClick to closeThe maximum amount TRICARE pays for each procedure or service. This is tied by law to Medicare's allowable charges. is the maximum amount a participating TRICARE provider can be paid for a covered service. Learn more about TRICARE provider types.
Health care costs can differ based on who you are and your health plan option. For specific plan costs and dollar amounts, use the TRICARE Compare Cost Tool. Also, download the 2019 TRICARE Costs and Fees Sheet. If you want to enroll in or change your TRICARE health plan during TRICARE Open Season, take command of your health benefit by understanding your health care costs.
Last Updated 11/30/2018