TRICARE Benefits Explained
Do you understand your TRICARE benefits? Do you know if you are enrolled in the TRICARE coverage plan that best suits your family's needs? Are you completely confused by all the TRICARE coverage options, co-pays, deductibles, and acronyms?
If so you are not alone, our surveys have found that most servicemembers and their families are confused by TRICARE. The fact is, TRICARE is an enormous and very complex health care system.
- The Facts
- Three Main Coverage Plans
- New TRICARE Young Adult
- Making the Choice
- Eligible Active Duty, Guard and Reserve Family Members
- Retirees (under 65), Their Family Members, and Others
- Other TRICARE Programs
- TRICARE Important Telephone Numbers
- TRICARE Enrollment and Forms
- TRICARE Claims Process and Forms
TRICARE Facts
TRICARE is a regionally managed health care program for Active Duty, Activated Guard and Reserves, Retired members of the uniformed services, their families, and survivors. TRICARE brings together the health care resources of the Army, Navy and Air Force and supplements them with networks of civilian health care professionals to provide better access and high quality service while maintaining the capability to support military operations.
Active Duty and Guard and Reserve servicemembers are automatically enrolled TRICARE Prime. However military dependents and retirees must choose the TRICARE option that best suits their needs.
TRICARE has three main coverage choices for health care:
- TRICARE Prime - where Military Treatment Facilities (MTFs) are the principal source of health care.
- TRICARE Extra - a preferred provider option that saves money; and
- TRICARE Standard - a fee-for-service option (the original CHAMPUS program);
Making the Choice
Your main challenge will probably be deciding which TRICARE option, Prime, Extra or Standard, is best for you. The following tables provide examples of cost-shares or copayments for families who use civilian providers and facilities under each of the three TRICARE options. The listed fees are subject to change.
Eligible Active Duty, Guard and Reserve Family Members:
|
TRICARE
Prime |
TRICARE
Extra |
TRICARE
Standard |
|
|
Annual Deductible
|
None
|
$150/individual or $300/family for E-5 & above; $50/$100 for E-4 & below
|
$150/individual or $300/family for E-5 & above; $50/100 E-4 below
|
|
Annual Enrollment Fee |
None
|
None
|
None
|
|
Civilian Outpatient Visit
|
No Cost
|
15% of negotiated fee
|
20% of allowed charges for covered service
|
|
Civilian Inpatient Admission
|
No Cost
|
Greater of $25 or $14.35/day
|
Greater of $25 or $14.35/day
|
|
Civilian Inpatient Behavioral Health
|
No Cost
|
Greater of $20 per day or $25 per admission
|
Greater of $20 per day or $25 per admission
|
|
Civilian Inpatient Skilled Nursing Facility Care
|
$0 per diem charge per admission
|
$11/day
($25 minimum) Charge per admission |
$11/day
($25 minimum) Charge per admission |
|
No separate co-payment/cost-share for separately billed professional charges
|
Retirees(under 65), Their Family Members, and Others
|
TRICARE
Prime |
TRICARE
Extra |
TRICARE
Standard |
|
|
Annual Deductible
|
None
|
$150/individual or
$300/family |
$150/individual or
$300/family |
|
Annual Enrollment Fee
|
$230/individual $460/family
|
None
|
None
|
|
Civilian Cost Shares
|
20% of negotiated
fee |
25% of allowed charges for covered service
|
|
|
Outpatient
Emergency Care Mental Health Visit |
$12
$30 $25 $17 (group visit) |
||
|
Civilian Inpatient
Cost Share |
Greater of $11 per day or $25 per admission; no separate copayment for separately billed professional charges
|
Lesser of $250/day or 25% of negotiated charges plus 20% of negotiated professional fees
|
Lesser of $535/day or 25% of billed charges plus 25% of allowed professional fees<
|
|
Civilian Inpatient Skilled Nursing Facility Care
|
$11/day
($25 minimum) charge per admission |
$250 per diem cost share or 20% cost share of total charges, whichever is less, institutional services, plus 20% cost share of separately billed professional charges
|
25% cost-share of allowed charges for institutional services, plus 25% cost-share of allowable for separately billed professional charges.
|
|
Civilian Inpatient Behavioral Health
|
$40 per day; no charge for separately billed professional charges
|
20% of total charge. Plus, 20% of the allowable charge for separately billed professional services
|
High Volume Hospitals - 25% hospital specifi per diem, plus 25% of the allowable charge for separately billed professional services; Low Volume Hospitals - $175 per day or 25% of the billed charges, whichever is lower, plus 25% of the allowable charge for separately billed services
|
Other TRICARE Programs
TRICARE has many other programs including TRICARE for Life, TRICARE Dental, etc... For more information see our TRICARE section, or click on the links below to learn more about:
- Defense Enrollment Eligibility Reporting System (DEERS)
- TRICARE Service Centers
- TRICARE Claims Process
- TRICARE Claims Forms
- TRICARE Eligibility
- Family Care Authorized
- Priority of Care
- TRICARE and Medicare
- TRICARE Cost Co-Pay Schedule
- TRICARE Extra
- TRICARE for Life
- TRICARE Overseas
- TRICARE Pharmacy Options
- TRICARE Prime
- TRICARE Prime Remote
- TRICARE Reserve and Guard Overview
- TRICARE Senior Pharmacy Program
- TRICARE Standard
- TRICARE Dental Plan (TDP)
- TRICARE DTP - Overseas
- TRICARE Retiree Dental Program (TRDP)
- TRICARE ECHO (Formerly PFPWD)
- TRICARE Plus
- US Family Health Plan
If you aren't sure whether TRICARE covers a service or supply, contact your Beneficiary Counseling and Assistance Coordinator (BCAC), Health Benefits Advisor (HBA), TRICARE Support Center (TSC), or your TRICARE contractor. They can advise you about covered services, but they can't guarantee payment by TRICARE. If you're enrolled in TRICARE Prime, be sure to see your Primary Care Manger (PCM) for a referral before getting any type of civilian specialized medical care.
The applicable Federal laws and 32 CFR Part 199 are the final word on any TRICARE issue. If any difference exists among this handbook, what anybody tells you, and the law and regulation, it's the law and regulation that apply (32 CFR 199) is on the Military Health System/TRICARE website.
You have several different TRICARE customer service options depending on what you need.
Beneficiary Counseling & Assistance Coordinator
Debt Collection Assistance Officer
Military Treatment Facility
TRICARE Service Center: North Region | South Region | West Region | Overseas Region
Regional Contractors
North Region 1.877.874.2273
Health Net Federal Services
South Region 1.800.444.5445
Humana Military Healthcare Services
West Region 1.888.874.9378
TriWest Healthcare Alliance
Eurasia-Africa Area 44.20.8762.8133
International SOS Country-Specific Contact Information
Latin America & Canada Area 1.215.924.8393
International SOS Country-Specific Contact Information
Pacific Area (Singapore) 65.6339.2676 (Sydney) 61.2.9273.2710
International SOS Country-Specific Contact Information
Other Contractors and Related Program
Other TRICARE-related Health Plans
TRICARE For Life 1.866.773.0404
US Family Health Plan 1.800.748.7347
Dental Programs
TRICARE Active Duty Dental Program 1.866.984.2337
TRICARE Dental Program (Stateside) 1.800.866.8499 (Overseas) 1.888.418.0466
TRICARE Retiree Dental Program 1.888.838.8737
Pharmacy Program
Express-Scripts, Inc. 1.877.363.1303
Other TRICARE Related Contacts
DEERS (Eligibility) 1.800.538.9552
Continued Health Care Benefit Program 1.800.444.5445
Military Medical Support Office 1.888.647.6676
TRICARE Online 1.800.600.9332
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