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|
|Maternity care (prenatal, postnatal)||$0||$0|
Well-child care (birth to age 6)
|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)
|Physical therapy (when medically necessary)||$0||$12|
|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
|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|
|Ambulance services (when medically necessary)8||$0||$20 per occurrence|
|Dental Care - basic preventive||Reduced fees||Reduced fees|
|Durable medical equipment||$0||20%|
|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)
$17 brand name
$44 Non-pref brand name
|Prescription drug co-pays6 (up to a 90 day supply)|
(Rite Aid Retail & Home Delivery)
$13 brand name
$43 Non-pref brand name
$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:
- 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.
- 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.
- Exclusive of drug maintenance programs.
- 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.
- Unless you are admitted to the hospital, in which case only the inpatient co-payment applies.
- 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.
- Outpatient treatment following the initial intake evaluation and testing is limited to a maximum of 36 sessions per cardiac event.
- Upon arrival of the ambulance and the member refuses transport, the member is liable/responsible for services rendered.