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

$323 individual
$647 family

$392 individual
$784 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

$22

$22

Specialty office visits

$0

$33

$33

Maternity care
(prenatal, postnatal)

$0

$0

$0

Well-child care (birth to age 6)

$0

$0

$0

Routine physical examinations5

$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

$67

$67

Physical Therapy
(when medically necessary)

$0

$33

$33

Cardiac Rehabilitation4

$0

$33

$33

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

$168/admission

$168/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

$33/visit

$33/visit

Outpatient group / family therapy

$0

$33/visit

$33/visit

Partial hospitalization, mental health

$0

$33/visit

$33/visit

Inpatient hospital psychiatric care

$0

$168/admission

$168/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

$33/visit

$33/visit

Outpatient group / family therapy

$0

$33/visit

$33/visit

Inpatient services (up to 7 days for detoxification per year)

$0

$168/admission

$168/admission

Residential Treatment Facility

$0

$33/day

$33/day

Partial hospitalization, substance abuse

$0

$33/visit

$33/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 ground6 (when medically necessary)

$0

$44/occurrence

$44/occurrence

Ambulance outpatient air6 (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

$67

$67

Urgent Care Center

$0

$33

$33

Routine eye examination (1 per Plan year)

$0

$0

$0

Radiation / chemotherapy office visits

$0

$33

$33

Prescription drug co-pays(up to a 30-day supply - Walgreens Retail)

$14 generic
$38 brand name
$68 non-preferred brand name

$14 generic
$38 brand name
$68 non-preferred brand name

$14 generic
$38 brand name
$68 non-preferred brand name

Prescription drug co-pays(up to a 90-day supply for maintenance medications - Home Delivery & Walgreens Retail)

$12 generic
$34 brand name
$68 non-preferred brand name

$12 generic
$34 brand name
$68 non-preferred brand name

$12 generic
$34 brand name
$68 non-preferred brand name

Skilled nursing facility care

$0

$33/day

$33/day

Home health care (part-time skilled nursing care)

$0

$0

$0

Out of area (emergency services only)

$0

$67

$67

Catastrophic cap (Maximum out-of-pocket expense per family)

$1,000/enrollment year (Group A*)
$1,120/enrollment year (Group B**)

$3,000/enrollment year

$3,921/enrollment year

*For enlistment or appointment prior to January 1, 2018 / **For enlistment or appointment after January 1, 2018
1
If lab services are provided on the same day as the office visit and a co-pay is collected for the visit, no additional co-pay will be collected. No co-pay will be collected when services are billed and provided as clinical preventive services. Exceptions: Co-pay may be required for certain radiation oncology, vascular and pulmonary procedures and studies. Contact Customer Service for details.
2
Unless you are admitted to the hospital, in which case only the inpatient co-payment applies
3
Prescription drug availability is limited to drugs prescribed by a Plan provider and covered as a Plan benefit. Availability of non-emergency prescriptions when out of the area is also limited
4
Outpatient treatment following the initial intake evaluation and testing is limited to a maximum of 36 sessions per cardiac event.
5
Routine Physical Examinations – while there is no co-pay for a Routine Physical; an office visit co-pay may be assessed if other procedures (not considered routine) are conducted during the examination.
6
Upon arrival of the ambulance and member refuses transport, the member is liable/responsible for services rendered