Looking for 2019 Benefits & Costs?

Overview of Medical Benefits & Costs

TRICARE Prime Benefits

Cost for Active-Duty Family Members
Cost for Retirees and their Family Members / Survivors

Premium Fees

$0

$289.08 individual / $578.16 family

Outpatient Services (subject to medical review)

Cost for Active-Duty Family Members
Cost for Retirees and their Family Members / Survivors

Office visits

$0

$20

Specialty office visits

$0

$30

Maternity care
(prenatal, postnatal)

$0

$0

Well-child care (birth to age 6)

$0

$0

Routine physical examinations6

$0

$0

X-ray and lab tests1

$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

$60

Physical Therapy
(when medically necessary)

$0

$30

Cardiac Rehabilitation

$0

$30

Inpatient Services (subject to medical review)

Cost for Active-Duty Family Members
Cost for Retirees and their Family Members / Survivors

Hospitalization
(semi-private room and board)

$0

$150/admission

Physician services

$0

$0

General nursing services

$0

$0

Diagnostic tests including lab and X-ray

$0

$0

Operating room, anesthesia and supplies

$0

$0

Medically necessary supplies and services

$0

$0

Physical therapy (when medically necessary)

$0

$0

Mental Health Services (subject to medical review)

Cost for Active-Duty Family Members
Cost for Retirees and their Family Members / Survivors

Outpatient care individual

$0

$30/visit

Outpatient group / family therapy

$0

$30/visit

Partial hospitalization mental health

$0

$30/visit

Inpatient hospital psychiatric care

$0

$150/admission

Substance Abuse Treatment (subject to medical review)

Cost for Active-Duty Family Members
Cost for Retirees and their Family Members / Survivors

Outpatient care individual

$0

$30/visit

Outpatient group / family therapy

$0

$30/visit

Inpatient services

$0

$150/admission

Inpatient rehabilitation / Partial hospitalization program

$0

$30/day

Other Service (subject to medical review)

Cost for Active-Duty Family Members
Cost for Retirees and their Family Members / Survivors

Ambulance services5 (when medically necessary)

$0

$40/occurrence

Dental Care - basic preventive

Reduced fees

Reduced fees

Durable medical equipment

$0

20%

Emergency room services2 (including out of the area)

$0

$60

Urgent care center

$0

$30

Routine eye examination (1 per year)

$0

$0

Radiation/chemotherapy office visits

$0

$30

Prescription drug co-pays3 (Walgreens)
(up to a 30-day supply)

$11 generic
$28 brand name
$53 non-preferred brand name

$11 generic
$28 brand name
$53 non-preferred brand name

Prescription drug co-pays3 (Home delivery only)
(up to a 90-day supply)

$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

Home health care (part-time skilled nursing care)

$0

$0

Out of area (emergency services only)

$0

$60

Catastrophic cap7

$1,000/enrollment year

$3,000/enrollment year

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. Over-the-counter medications and supplies are not covered. Retail vendors for prescriptions are Rite Aid and Walgreens pharmacies.
4
Outpatient treatment following the initial intake evaluation and testing is limited to a maximum of 36 sessions per cardiac event.
5
Upon arrival of the ambulance and member refuses transport, the member is liable/responsible for services rendered.
6
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.
7
Annual premiums do not apply toward the catastrophic cap.