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