| OTHER HEALTH CARE | ||||||||
| Prime | Standard/Extra | |||||||
| Type of Service or Fees | Active Duty Spouse | Retiree or Retiree Spouse | Active Duty Daughter | Retiree Daughter | Active Duty Spouse | Retiree or Retiree Spouse | Active Duty Daughter | Retiree Daughter |
| Annual Enrollment Fee (includes ALL health care under Prime | $0 | $230/individual, $460/family | $0 | $230/individual, $460/family | N/A | N/A | N/A | N/A |
| Annual Fiscal Year Deductible (Applicable to outpatient services) | N/A3 | N/A3 | N/A3 | N/A3 | $50/individual or $100/family for E-4 and below. $150/individual or $300/family for E-5 and above. | $150 per individual or $300 per family. | $50/individual or $100/family for E-4 and below. $150/individual or $300/family for E-5 and above. | $150 per individual or $300 per family. |
| MTF Hospital | $0 | $13.322/day | $0 | $13.322/day | $13.322/day | $13.322/day | $13.322/day | $13.322/day |
| MTF Outpatient | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| Civilian Inpatient (Network Hospital) | $0 | $11/day ($25 minimum charge per admission). | $0 | $11/day ($25 minimum charge per admission). | $13.322/day ($25 minimum charge per admission). | Lesser of $250/day or 20% of the fee negotiated by TRICARE contractor for institutional services, plus 20% of the professional fee. | $13.322/day ($25 minimum charge per admission). | Lesser of $250/day or 20% of the fee negotiated by TRICARE contractor for institutional services, plus 20% of the professional fee. |
| Civilian Outpatient (Network Provider) | $0 | $12
outpatient $30 emergency care $25 mental health ($17 group) |
$0 | $12
outpatient $30 emergency care $25 mental health ($17 group) |
15% of the fee negotiated by TRICARE contractor | 20% of the fee negotiated by TRICARE contractor | 15% of the fee negotiated by TRICARE contractor | 20% of the fee negotiated by TRICARE contractor |
| Civilian Inpatient (Non- Network Hospital) | 50% of the allowed charges under the Point-of Service- option. | 50% of the allowed charges under the Point-of Service- option. | 50% of the allowed charges under the Point-of Service- option. | 50% of the allowed charges under the Point-of Service- option. | Greater of $25 or $13.322/day. | Lesser of $4592/day (441/day effective May 1, 04) or 25% of billed charges plus 25% of allowed professional fees. | Greater of $25 or $13.322/day. | Lesser of $4592/day (441/day effective May 1, 04) or 25% of billed charges plus 25% of allowed professional fees. |
| Civilian Outpatient (Non- Network Provider) | 50% of the allowed charges under the Point of Service option3 | 50% of the allowed charges under the Point of Service option3 | 50% of the allowed charges under the Point-of Service option3 | 50% of the allowed charges under the Point of Service option3 | 20%1 of allowed charges for covered service | 25%1 of allowed charges for covered service | 20%1 of allowed charges for covered service | 25%1 of allowed charges for covered service |
| Civilian Inpatient Mental Health (Network) | $0 | $40/day | $0 | $40/day | $20/day ($25 minimum charge) | 20% of institutional fee negotiated by TRICARE contractor plus 20% of professional fee negotiated by TRICARE contractor | $20/day ($25 minimum charge) | 20% of institutional fee negotiated by TRICARE contractor plus 20% of professional fee negotiated by TRICARE contractor |
| Civilian Inpatient Mental Health (Non- Network) | 50% of the allowed charges under the Point of Service option | 50% of the allowed charges under the Point of Service option | 50% of the allowed charges under the Point of Service option | 50% of the allowed charges under the Point of Service option | $20/day ($25 minimum charge) | High Volume Hospital:
25% of hospital specific
per diem.
Low Volume Hospital:
Lesser of $1642/day
or 25% of billed charge.
Residential Treatment
Center:
25% of the allowed amount.
Partial Hospitalization:
25% of the allowable
amount, plus 25% of allowable professional charges. |
$20/day ($25 minimum charge) | High Volume Hospital:
25% of hospital specific
per diem.
Low Volume Hospital:
Lesser of $1642/day
or 25% of billed charge.
Residential Treatment
Center:
25% of the allowed amount.
Partial Hospitalization:
25% of the allowable
amount, plus 25% of allowable professional charges. |
| Civilian Inpatient Skilled Nursing Facility Care (Network) | $0 | $11/day ($25 minimum charge per admission). | $0 | $11/day ($25 minimum charge per admission). | $13.322/day ($25 minimum charge per admission). | Lesser of $250/day or 20% of the fee negotiated by TRICARE contractor for institutional services, plus 20% of the professional fee negotiated by TRICARE contractor. | $13.322/day ($25 minimum charge per admission). | Lesser of $250/day or 20% of the fee negotiated by TRICARE contractor for institutional services, plus 20% of the professional fee negotiated by TRICARE contractor. |
| Civilian Inpatient Skilled Nursing Facility Care (Non-Network) | 50% of the allowed charges under the Point of Service option. | 50% of the allowed charges under the Point of Service option. | 50% of the allowed charges under the Point of Service option. | 50% of the allowed charges under the Point of Service option. | $13.322/day ($25 minimum charge per admission). | 25% of allowed charges for institutional services, plus 25%1 of allowable professional charges. | $13.322/day ($25 minimum charge per admission). | 25% of allowed charges for institutional services, plus 25%1 of allowable professional charges. |
| Home Health Care (Network) | $0 | $12/visit | $0 | $12/visit | 15% of the fee negotiated by TRICARE contractor | 20% of the fee negotiated by TRICARE contractor | 15% of the fee negotiated by TRICARE contractor | 20% of the fee negotiated by TRICARE contractor |
| Home Health Care (Non- Network) | 50% of the allowed charges under the Point of Service option3 | 50% of the allowed charges under the Point of Service option3 | 50% of the allowed charges under the Point of Service option3 | 50% of the allowed charges under the Point of Service option3 | 20%1 of the allowable charge | 25%1 of the allowable charge | 20%1 of the allowable charge | 25%1 of the allowable charge |
| Ambulatory Surgery (Network) | $0 | $25 | $0 | $25 | $25 | 20% of the fee negotiated by TRICARE contractor | $25 | 20% of the fee negotiated by TRICARE contractor |
| Ambulatory Surgery (Non- Network) | 50% of the allowed charges under the Point of Service option. | 50% of the allowed charges under the Point of Service option. | 50% of the allowed charges under the Point of Service option. | 50% of the allowed charges under the Point of Service option. | $251 | Lesser of 25% of group rate or 25% of billed charge1 | $251 | Lesser of 25% of group rate or 25% of billed charge1 |
| Durable Medical Equipment (DME), Prosthetic Devices, and Medical Supplies | 0% of the fee negotiated by TRICARE contractor | 20% of the fee negotiated by TRICARE contractor | 0% of the fee negotiated by TRICARE contractor | 20% of the fee negotiated by TRICARE contractor | Standard:
20%1 of the
allowable charge.
Extra:
15% of the fee negotiated
by TRICARE contractor. |
Standard:
25%1 of the
allowable charge.
Extra:
20% of the fee negotiated
by TRICARE contractor. |
Standard:
20%1 of the
allowable charge.
Extra:
15% of the fee negotiated
by TRICARE contractor. |
Standard:
25%1 of the
allowable charge.
Extra:
15% of the fee negotiated
by TRICARE contractor. |
| Ambulance Services | $0 | $20 per occurrence | $0 | $20 per occurrence | Standard:
20%1 of the
allowable charge.
Extra:
15% of the fee negotiated
by TRICARE contractor. |
Standard:
25%1 of the
allowable charge.
Extra:
20% of the fee negotiated
by TRICARE contractor. |
Standard:
20%1 of the
allowable charge.
Extra:
15% of the fee negotiated
by TRICARE contractor. |
Standard:
25%1 of the
allowable charge.
Extra:
20% of the fee negotiated
by TRICARE contractor. |
| Laboratory X-Ray, and Ancillary Services | $0 | $12 per visit. Note: No copay when provided and billed as clinical preventive services and no copay for specified CPT code ranges. | $0 | $12 per visit. Note: No copay when provided and billed as clinical preventive services and no copay for specified CPT code ranges. | Standard:
20%1 of the allowable charge. Extra:
15% of the fee negotiated by TRICARE contractor. |
Standard:
25%1 of the allowable charge. Extra:
20% of the fee negotiated by TRICARE contractor. |
Standard:
20%1 of the allowable charge. Extra:
15% of the fee negotiated by TRICARE contractor. |
Standard:
25%1 of the allowable charge. Extra:
20% of the fee negotiated by TRICARE contractor. |
| Clinical Preventive Services | $0 | $0 | $0 | $0 | Not covered |
Not covered |
Not covered |
Not covered |
| Routine Pap Smears | $0 | $0 | $0 | $0 | Standard:
20%1 of the allowable charge. Extra:
15% of the fee negotiated by TRICARE contractor. |
Standard:
25%1 of the allowable charge. Extra:
20% of the fee negotiated by TRICARE contractor. |
Standard:
20%1 of the allowable charge. Extra:
15% of the fee negotiated by TRICARE contractor. |
Standard:
25%1 of the allowable charge. Extra:
20% of the fee negotiated by TRICARE contractor. |
| MTF Pharmacy | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
| TRICARE Retail Network Pharmacy | $3/generic $9/brand (30-day supply) |
$3/generic $9/brand (30-day supply) |
$3/generic $9/brand (30-day supply) |
$3/generic $9/brand (30-day supply) |
$3/generic $9/brand (30-day supply) |
$3/generic $9/brand (30-day supply) |
$3/generic $9/brand (30-day supply) |
$3/generic $9/brand (30-day supply) |
| TRICARE Mail Order Pharmacy | $3/generic $9/brand (30-day supply) |
$3/generic $9/brand (30-day supply) |
$3/generic $9/brand (30-day supply) |
$3/generic $9/brand (30-day supply) |
$3/generic $9/brand (30-day supply) |
$3/generic $9/brand (30-day supply) |
$3/generic $9/brand (30-day supply) |
$3/generic $9/brand (30-day supply) |
| Non-network Pharmacy4 | 50% of cost | 50% of cost | 50% of cost | 50% of cost | > of $9 or 20% of cost | > of $9 or 20% of cost | > of $9 or 20% of cost | > of $9 or 20% of cost |
| Catastrophic Cap | $1000 | $3000 | $10005 | $30005 | $1000 | $3000 | $10005 | $30005 |
