|
Services Covered
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TRICARE Prime** |
TRICARE Extra* |
TRICARE Standard* |
Ancillary Services
Certain diagnostic radiology and ultrasound (70000-76999); diagnostic nuclear medicine (78000-78999); pathology and laboratory services (80000-89399); and cardiovascular studies (93000-93350) |
Per visit:
ADFM: No copayment
Retirees and others:
No copayment
|
ADFM: 15% of contracted reimbursement
Retirees and others: 20% of contracted reimbursement
|
ADFM: 20% of the maximum allowable charge
Retirees and others: 25% of the maximum allowable charge
|
Ambulance Services
When medically necessary and when needed for a medical condition that is covered by TRICARE |
Per occurrence:
ADFM: No copayment
Retirees and others: $20 copayment
|
Same as above |
Same as above |
|
Ambulatory Surgery (Same Day)(1)
When surgery is conducted at a hospital based or freestanding ambulatory surgical center that is TRICARE-certified TRICARE Prime Retirees and others copayment is applied to the ambulatory surgical facility only.
|
Per occurrence:
ADFM: No copayment
Retirees and others:
$25 copayment
|
ADFM:
$25 copayment
Retirees and others:
Professional—20% of contracted reimbursement
Facility—20% of contracted reimbursement
|
ADFM:
$25 copayment
Retirees and others:
Professional—25% of the maximum allowable charge Facility—25% of the group rate or 25% of billed charges; whichever is less
|
Durable Medical Equipment (DME), Prosthetic Devices and Medical Supplies (Prescribed by a Physician)(1)(3)
For DME, prosthetic devices, and medical supplies, care is subject to TRICARE policy after an office or home health visit when medically necessary and a covered benefit. |
ADFM: No copayment
Retirees and others:
20% of contracted reimbursement
|
ADFM: 15% of contracted reimbursement
Retirees and others:
20% of contracted reimbursement
|
ADFM: 20% of the maximum allowable charge
Retirees and others: 25% of the maximum allowable charge
|
Emergency Services(1)
Emergency care obtained on an outpatient basis, both network and non-network, in or out of the region |
Per visit:
ADFM: No copayment
Retirees and others: $30 copayment
|
Same as above |
Same as above |
Eye Examinations
One routine examination per year for active duty family members. For additional coverage, see “Eye Examinations” under Clinical Preventive Services Benefits. |
ADFM: No copayment
Retirees and others: Not covered
|
ADFM: 15% of contracted reimbursement
Retirees and others: Not covered
|
ADFM: 20% of the maximum allowable charge
Retirees and others: Not covered
|
Individual Provider Service(1)
Office visits; outpatient office-based medical and surgical care; consultation, diagnosis, and treatment by a specialist; allergy tests and treatment; osteopathic manipulation; rehabilitation services, e.g., physical therapy, speech pathology services, and occupational therapy; medical supplies used within the office, including casts, dressings, and splints. |
Per visit:
ADFM: No copayment
Retirees and others: $12 copayment
|
ADFM: 15% of contracted reimbursement
Retirees and others: 20% of contracted reimbursement |
ADFM: 20% of the maximum allowable charge
Retirees and others: 25% of the maximum allowable charge |
Immunizations for Required
Overseas Travel
Immunizations required for ADFMs whose sponsors have permanent change-of-station orders to overseas locations. |
Per Visit:
ADFM: No copayment
Retirees and others: Not covered |
ADFM: 15% of contracted reimbursement
Retirees and others: Not covered |
ADFM: 20% of the maximum allowable charge
Retirees and others: Not covered |
Laboratory and X-Ray Services (provided as part of an office visit) (1)(2)
TRICARE Prime Retirees and others do not have an additional copayment if these services are provided as part of an office visit. |
Per visit:
ADFM: No copayment
Retirees and others: $12 copayment |
ADFM: 15% of contracted reimbursement
Retirees and others: 20% of contracted reimbursement |
ADFM: 20% of the maximum allowable charge
Retirees and others: 25% of the maximum allowable charge |
*Cost-share is applied after deductible has been satisfied.
**Benefits under TRICARE Prime Remote (TPR) and TRICARE Prime Remote for Active Duty Family Members (TPRADFM) are similar to TRICARE Prime. |
1. TRICARE Standard beneficiaries may pay up to 15 percent above the maximum allowable charge when the provider does not accept assignment (balance billing). See the Glossary for a description of balance billing.
2. If provided as part of an office visit and a copayment is collected for the visit under TRICARE Prime, no additional copayment will be collected for these services.
3. Requires prior authorization for TRICARE Prime, TPR, and TPRADFM, depending on the item or amount billed. |
