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Summary of Costs & Benefits

TRICARE Prime Benefits

 

Cost for Active Duty Family Members

Cost for Retirees, Family Members and Survivors

 
Premium Fees$0$277.92 individual / $555.84 family 

Outpatient Services

Office visits$0$12 
Maternity care (prenatal, postnatal)$0$0 

Well-child care (birth to age 6)

$0$0 
Routine physical examinations$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$25 
Physical therapy (when medically necessary)$0$12 
Cardiac Rehabilitation7$0$12 

Inpatient Services

Hospitalization (semi-private room and board)$0$11 per day/$25 minimum
charge for admission
 
Maternity care (prenatal, delivery, postnatal hospital and professional services)$0

$11 per day/$25 minimum
charge for 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

Outpatient care individual (subject to medical review)$0$25 per visit 
Outpatient group / family therapy (subject to medical review)$0$17 per visit 
Partial hospitalization mental health (up to 60 days per fiscal year)$0$40 per day 
Inpatient hospital psychiatric care (subject to medical review)2$0$40 per day 

Substance Abuse Treatment

Outpatient care (individual)3$0$25 per visit 
Outpatient group/family therapy$0$17 per visit 
Inpatient services (up to 7 days for detoxification per year)4$0$40 per day 
Inpatient rehabilitation / Partial hospitalization program (PHP) (up to 21 days per year)4$0$40 per day 

Other Services

Ambulance services (when medically necessary)8$0$20 per occurrence 
Dental Care - basic preventiveReduced feesReduced fees 
Durable medical equipment$020% 
Emergency room services5 (including out of the area)$0$30 
Routine eye examination (1 per year)$0$0 
Family planning services$0$12 
Radiation/chemotherapy office visits$0$12 
Prescription drug co-pays6 (up to a 30 day supply)
(Rite Aid Retail)

$5 generic
$17 brand name
$44 Non-pref brand name

$5 generic
$17 brand name
$44 Non-pref brand name
 
Prescription drug co-pays6 (up to a 90 day supply)
(Rite Aid Retail & Home Delivery)
$0 generic
$13 brand name
$43 Non-pref brand name
$0 generic
$13 brand name
$43 Non-pref brand name
 
Skilled nursing facility care$0$11 per day/$25 minimum
charge per admission
 
Home health care (part-time skilled nursing care)$0$12 per visit 
Out of area (emergency services only)$0$30 
Catastrophic cap$1,000 per enrollment yr.$3,000 per enrollment yr. 


Footnotes to chart:

  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. With authorization, up to 30 days per enrollment year for adults (age 19+); up to 45 days per enrollment year for children under age 19; up to 150 days of residential treatment for children and adolescents.
  3. Exclusive of drug maintenance programs.
  4. Maximum of one rehabilitation program per year and three per lifetime. Detoxification and rehabilitation days count toward limit for substance abuse benefits. The beneficiary may have either 21 days of rehabilitation in a residential (inpatient) basis or 21 days of rehabilitation in a partial hospital setting or a combination of both, as long as the 21-day limit for the total rehabilitation period is not exceeded.
  5. Unless you are admitted to the hospital, in which case only the inpatient co-payment applies.
  6. 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 vendor for prescriptions is Rite Aid Pharmacy.
  7. Outpatient treatment following the initial intake evaluation and testing is limited to a maximum of 36 sessions per cardiac event.
  8. Upon arrival of the ambulance and the member refuses transport, the member is liable/responsible for services rendered.

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