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.

We can help clarify many of your questions and concerns. You owe it to yourself and your family to find out as much as you can about TRICARE before making any decisions! The following provides a summary of this complex program:

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);

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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.

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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

 

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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

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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:

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.

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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

The North, South and West contractors provide customer service for all plans except TRICARE For Life and the US Family Health Plan. The overseas contractor provides customer service for all overseas plans.

North Region 1.877.874.2273
Health Net Federal Services

South Region 1.800.444.5445
Humana Military Healthcare Services

West Region 1-877-988-9378 
United Healthcare Military & Veteran

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

For customer service for pharmacy, dental, other health plan options and other TRICARE-related organizations, please use the list below.

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

Related Topics

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