Your Medical Benefits & Costs
TRICARE Prime Benefits
Cost for Active-Duty
Family Members
Cost for Retirees and their
Family Members / Survivors
Group A* / Group B**
Group A*
Group B**
Annual Enrollment Fees
$0
$297 individual
$594 family
$360 individual
$720 family
Annual Deductibles
$0
$0
$0
Outpatient Services (subject to medical review)
Cost for Active-Duty
Family Members
Cost for Retirees and their
Family Members / Survivors
Group A* / Group B**
Group A*
Group B**
Preventative visit
$0
$0
$0
Office Visits (Primary Care)
$0
$20
$20
Specialty office visits
$0
$30
$30
Maternity care
(prenatal, postnatal)
$0
$0
$0
Well-child care (birth to age 6)
$0
$0
$0
Routine physical examinations6
$0
$0
$0
X-ray and lab tests1
$0
$0
$0
Ambulatory surgery
(same day)
All surgical procedures (regardless of where they are performed; excluding some venipuncture and fetal monitoring procedures) and birthing centers (prenatal care, outpatient delivery, and postnatal care)
$0
$61
$61
Physical Therapy
(when medically necessary)
$0
$30
$30
Cardiac Rehabilitation
$0
$30
$30
Inpatient Services (subject to medical review)
Cost for Active-Duty
Family Members
Cost for Retirees and their
Family Members / Survivors
Group A* / Group B**
Group A*
Group B**
Hospitalization
(semi-private room and board)
$0
$154/admission
$154/admission
Physician services
$0
$0
$0
General nursing services
$0
$0
$0
Diagnostic tests including lab and X-ray
$0
$0
$0
Operating room, anesthesia and supplies
$0
$0
$0
Medically necessary supplies and services
$0
$0
$0
Physical therapy (when medically necessary)
$0
$0
$0
Mental Health Services (subject to medical review)
Cost for Active-Duty
Family Members
Cost for Retirees and their
Family Members / Survivors
Group A* / Group B**
Group A*
Group B**
Outpatient care individual
$0
$30/visit
$30/visit
Outpatient group / family therapy
$0
$30/visit
$30/visit
Partial hospitalization, mental health
$0
$30/visit
$30/visit
Inpatient hospital psychiatric care
$0
$154/admission
$154/admission
Substance Abuse Treatment (subject to medical review)
Cost for Active-Duty
Family Members
Cost for Retirees and their
Family Members / Survivors
Group A* / Group B**
Group A*
Group B**
Outpatient care individual
$0
$30/visit
$30/visit
Outpatient group / family therapy
$0
$30/visit
$30/visit
Inpatient services (up to 7 days for detoxification per year)
$0
$154/admission
$154/admission
Inpatient rehabilitation
$0
$30/visit
$30/visit
Other Service (subject to medical review)
Cost for Active-Duty
Family Members
Cost for Retirees and their
Family Members / Survivors
Group A* / Group B**
Group A*
Group B**
Ambulance, outpatient ground5 (when medically necessary)
$0
$41/occurrence
$41/occurrence
Ambulance outpatient air5 (when medically necessary)
$0
$20/occurrence
$20/occurrence
Dental Care (basic preventative)
Reduced fees
Reduced fees
Reduced fees
Durable medical equipment
$0
20%
20%
Emergency room services2 (including out of the area)
$0
$61
$61
Urgent Care Center
$0
$30
$30
Routine eye examination (1 per Plan year)
$0
$0
$0
Radiation / chemotherapy office visits
$0
$30
$30
Prescription drug co-pays3 (up to a 30-day supply - Walgreens Retail)
$11 generic
$28 brand name
$53 non-preferred brand name
$11 generic
$28 brand name
$53 non-preferred brand name
$11 generic
$28 brand name
$53 non-preferred brand name
Prescription drug co-pays3 (up to a 90-day supply for maintenance medications - Home Delivery & Walgreens Retail)
$7 generic
$24 brand name
$53 non-preferred brand name
$7 generic
$24 brand name
$53 non-preferred brand name
$7 generic
$24 brand name
$53 non-preferred brand name
Skilled nursing facility care
$0
$30/day
$30/day
Home health care (part-time skilled nursing care)
$0
$0
$0
Out of area (emergency services only)
$0
$60
$60
Catastrophic cap7 (Maximum out-of-pocket expense per family)
$1,000/enrollment year (Group A*)
$1,028/enrollment year (Group B**)
$3,000/enrollment year
$3,598/enrollment year
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