TRICARE Standard Overview

Choosing the right TRICARE coverage plan for your family is difficult. Each of the three TRICARE options are designed to fit the needs of the individual beneficiary. Understanding the following factors will assist you in determining if TRICARE Standard is your best choice.

TRICARE Standard is the TRICARE option that provides the most flexibility to TRICARE-eligible beneficiaries. It is the fee-for-service option that gives beneficiaries the opportunities to see any TRICARE-authorized provider. TRICARE Standard is not available to active duty service members. Standard shares most of the costs of medically necessary care from civilian providers when military treatment facility (MTF) care is unavailable.

Reasons for Choosing TRICARE Standard:

Beneficiaries who are happy with the treatment they currently receive from a specific civilian provider that may not be in the TRICARE provider network often choose to use TRICARE Standard. Some beneficiaries, especially retirees under age 65 and their families, may live in areas where the TRICARE Prime network is not available, and TRICARE Standard may be their only option. Additionally, retired service members may have employer-sponsored health insurance. TRICARE Standard may be used as secondary coverage for these beneficiaries.

Standard's Pros - Advantages

  • Broadest choice of providers
  • Widely available
  • No enrollment fee
  • You may also use TRICARE Extra

Standard's Cons - Disadvantages

  • No Primary Care Manager
  • Patient pays Deductible and Co-payment
  • Patient pays balance if bill exceeds allowable charge and provider is non-participating (up to 15% additional)
  • Nonavailability statement may be required for civilian inpatient care for areas surrounding MTFs
  • Beneficiaries may have to do their own paperwork and file their own claims

The Point of Service annual deductible and cost-share amounts do not count toward your enrollment-year maximum out-ofpocket expense, but instead are credited to your fiscal year maximum. There is no limit to the amount of a patient?s responsibility under the POS option.

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TRICARE Standard Features:

TRICARE Standard offers greater provider choice. Beneficiaries may choose any TRICARE-authorized provider. TRICARE-authorized providers are not required to participate in the TRICARE network; however, they must be certified as an authorized provider by the managed care support contractor (MCSC) in that region. Beneficiaries should contact their regional MCSC to find a TRICARE authorized provider.

TRICARE Standard allows beneficiaries to self-refer for specialty care. Beneficiaries who choose TRICARE Standard are not assigned a primary care manager, so, in most cases, they are able to see specialists without prior authorization. There are some outpatient procedures that require prior authorization. Beneficiaries should contact their regional contractor for authorization assistance before seeking care.

For inpatient mental health care, pre-authorization and continued stay authorization requirements apply to Residential Treatment Center care, partial hospitalization program care, and alcoholism detoxification and rehabilitation. All beneficiaries should contact TRICARE regional contractors regarding potential limits on length-of-stay at these facilities. TRICARE Standard beneficiaries living in an MTF catchment area must obtain a non-availability statement from their local MTF before being admitted as an inpatient for mental health services.

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Costs for TRICARE Standard:

Beneficiaries are responsible for cost shares and deductibles for care that is covered under TRICARE Standard. Providers who participate in TRICARE will accept the TRICARE allowable charge (TAC) as the full fee for services they render. However, non-participating providers may charge up to 15 percent above the TAC for their services, and TRICARE Standard beneficiaries are financially responsible for these additional charges.

A "catastrophic cap" is the annual upper limit a family will have to pay for TRICARE Standard-covered services in any fiscal year. The catastrophic cap for families of active duty service members is $1,000. All others have a catastrophic cap of $3,000. The catastrophic cap applies only to allowable charges for covered services. The catastrophic cap does not apply to services that are not covered, or to the total amount of what nonparticipating providers may charge above the TAC.

The chart below shows the costs beneficiaries may incur under TRICARE Standard:

Family Members of Active Duty Service Members

Retirees, Their Family Members and Others

Annual Deductible

$150 per individual or $300 per family for E-5 and above; $50 per individual or $100 per family for E-4 and below.

$150 per individual or $300 per family

Cost Share

(outpatient visits, emergency care and mental health visits)

20 percent of allowable charges

25 percent of allowable charges

Civilian Inpatient Cost Share

Greater of $25 or $15.65* per day

Lesser of $535* per day or 25 percent of billed charges plus 25 percent of allowed separately billed professional fees

Civilian Inpatient Mental Health

Greater of $20 per day or $25 per admission

Lesser of $193* per day or 25 percent of allowable fees plus 25 percent of allowed separately billed professional fees

*FY 2009; rates change every fiscal year

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Getting Help With TRICARE:

TRICARE Standard has specific rules, and beneficiaries choosing to use TRICARE Standard may need to contact the regional contractor call centers toll free number or a beneficiary counseling and assistance coordinator (BCAC) in their area for assistance. Customer service staff can answer specific questions about health care benefits, billing or claims as well as provide help navigating through the Military Health System. TRICARE Beneficiaries may locate a BCAC online.

Helpful Hints on TRICARE Standard:

TRICARE Contact Numbers:

  • TRICARE For Life Program 1-866-773-0404
  • Pharmacy Program 1-877-363-1303
  • US Family Health Plan 1-800-748-7347
  • TRICARE Dental Program 1-800-866-8499
  • TRICARE Active Duty Dental Plan 1-866-984-2337
  • TRICARE Retiree Dental Program 1-888-838-8737
  • Active Duty Claims (Military Medical Support Office) 1-888-647-6676

For general information about TRICARE, call the toll-free TRICARE information line for your region found at the TRICARE Contact Us web page.

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