Coverage Details

These costs are effective 1/1/2020.

Service Cost
Annual Deductible Network Providers: $0
Point-of-Service Option: $300 for individuals, $600 for family
Ambulance Services $41 per occurrence
Ambulatory Surgery (Same Day) $62
Mental Health (Inpatient) See TRICARE Mental Health Costs
Mental Health (Partial Hospitalization) See TRICARE Mental Health Costs
Mental Health (Outpatient) See TRICARE Mental Health Costs
Clinical Preventive Services $0 from a network provider
DME, Prosthetic Devices, Medical Supplies 20% of the negotiated fee. The discounted rate network providers agree to accept for covered services.
Emergency Services $62 per visit
Home Health Care $0.

Note: You may have separate costs for additional services when receiving home health care. For example, DME, drugs, vaccines, orthotics/prosthetics, and nutritional therapy, among others.

Hospice Care $0
Hospitalization (Inpatient Care) Network Hospital: $156 per admission
Immunizations $0 from a network provider
Laboratory and X-ray Ancillary* services: $0
Other Radiology services: $0
Maternity (office visits and hospitalization for delivery planned in a hospital in an inpatient setting) Office Visits: $0
Delivery: $156
Maternity (office visits for delivery planning in a TRICARE-authorized birthing center) Office Visits: $0
Delivery: $62
Maternity (office visits for delivery planned at home or other setting)

Primary Care Provider: $20 per visit

Specialty Care Provider: $31 per visit

Newborn Care $0
Outpatient Visit Primary Care: $20 per visit
Specialty Care: $31 per visit
Skilled Nursing (Inpatient) $31 per day
Urgent Care $31 per visit


Disclaimer:  When TRICARE Prime enrollees other than active duty service members self-refer to specialty or non-emergent inpatient care without a referral from a network provider and/or authorization from the regional contractor, the TRICARE Point of Service deductible and copayment applies in lieu of TRICARE Prime copayments. 




Last Updated: 11/05/2019