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Avoid Surprise Bills (Article 12)
Follow These Tips to Minimize Out-of-Pocket Health Care Costs  

Let’s face it. Unexpected health care bills are a drag.

A little bit of knowledge about your TRICARE Prime benefits goes a long way toward helping you make effective health care decisions while minimizing your out-of-pocket costs (copayments, cost-shares and deductibles).

Here are a few ways you can save.


The MTF: Your Lowest Cost Option for Care

Whenever possible, seek care within a military treatment facility (MTF). This is your lowest cost option for receiving care. Outpatient services are provided at no cost to beneficiaries. Inpatient services are also free to active duty service members (ADSMs), their families and retirees. Retirees’ families pay a low copayment for hospitalization.

Active duty service members, followed by TRICARE Prime beneficiaries, have the highest priority to receive care at the MTF.

To find an MTF near you, visit the MTF Locator on the TRICARE Web site or visit the Humana Military Provider Locator.

Network Providers
When services are not available at an MTF, the MTF and your regional contractor will assist you in coordinating your care with a TRICARE network provider—your next best option for minimizing out-of-pocket costs.

Non-network Providers
If a network provider is not available, you may seek care from a non-network provider only if you obtain a referral from your primary care manager (PCM) and an authorization from your regional contractor.

Point-of-Service Option

Should you bypass referral and authorization requirements, you’ll be responsible for additional costs under the TRICARE Prime point-of-service (POS) option.

The POS option lets TRICARE Prime enrollees receive nonemergency, TRICARE-covered services from any TRICARE-authorized/certified provider without referral or authorization. The POS option features higher out-of-pocket costs, however, so it is advisable to avoid using this option whenever possible.

The chart below describes the costs incurred by TRICARE Prime beneficiaries who use the POS option.

Point-of-Service Option Costs
Charges Individual Family
Deductible per fiscal year—for outpatient care only $300 $600
Cost-share for outpatient care 50% of TRICARE allowable charge, after annual deductible is met
Cost-share for inpatient care 50% of TRICARE allowable charge
Additional charges by certain non-network providers Up to 15% above the allowable charge is permitted by law; fully paid by the beneficiary
Even if you visit a TRICARE network provider, you must get a PCM referral and regional contractor authorization for certain health care services; otherwise, the POS charges apply.

Covered Services, Referrals and Authorizations

The best way to avoid incurring POS charges, as well as paying completely out of pocket for non-covered services, is to check TRICARE coverage before receiving care.

Refer to your TRICARE Prime Handbook for listings of excluded services, limited services and specialty care services that require PCM referral and regional contractor authorization. If you are still unsure, call Humana Military at 1-800-444-5445 to speak with a representative.

 Keeping Your Prescription Costs Down

Selecting generic drugs (when available) and filling your prescriptions at an MTF are your most cost-effective options. Avoiding non-network pharmacies will save you from paying top-dollar for your prescriptions.

By using the TRICARE Mail Order Pharmacy program, you can obtain a 90-day supply of medication for the same copayment that you’d pay for a 30-day supply at a TRICARE retail pharmacy.

Additionally, some drugs require prior authorization from Express Scripts, Inc. (ESI), the TRICARE pharmacy benefit contractor. Without it, you could be required to pay the entire cost of the medication.

Visit the Express Scripts Web site  or call 1-866-DoD-TRRx for more information.


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Last Reviewed:  December 4, 2007