TRICARE Standard/TRICARE Retired Reserve/TRICARE Young Adult Standard

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2 TRICARE Benefits Cost Chart View our Benefits A-Z page for benefit information. Important points to remember regarding copayments and cost-shares: Subject to change at the beginning of each year (October 1). Copayments are per occurrence or per visit. Point-of-service (POS) cost-shares and deductibles may apply to TRICARE Prime, TRICARE Prime Remote and TRICARE Young Adult Prime TRICARE Standard including TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR) and TRICARE Young Adult (TYA) Standard, may be required to pay up to 15 percent above the TRICARE allowed amount when using a non-participating provider. TRICARE Standard (including TRS, TRR and TYA Standard) cost-shares are applied to outpatient services once the deductible is met. A copayment of $17.05 per day for hospitalization/inpatient care provided at a military treatment facility may apply. Cost Chart Active Duty Family Members Retired Service Members and Their Families TRICARE Prime/ TRICARE Prime Remote/TRICARE Young Adult Prime Allergy Services TRICARE Standard/TRICARE Reserve Select/TRICARE Young Adult Standard allowed TRICARE Prime/ TRICARE Young Adult Prime TRICARE Standard/TRICARE Retired Reserve/TRICARE Young Adult Standard Ambulance Services Ambulatory Surgery (same day) in an outpatient hospital or ambulatory surgery center (ASC) Ancillary Services (Cardiovascular studies, diagnostic radiology and pathology) allowed $20 copayment $25 copayment 2 no deductible $25 copayment 2 allowed Breast MRIs (Screening) 1 No cost-share, no deductible No cost-share, no deductible Breast MRIs (Diagnostic) allowed Cardiovascular Disease Screenings 1 (Includes cholesterol and blood pressure screenings) Non-network Provider: 20% of allowed

3 Chemotherapy/Radiation Treatments allowed Clinical Preventive Exams 1 No cost-share, no deductible No cost-share, no deductible Colonoscopies (Preventive) or other colon cancer screenings 1 No cost-share, no deductible No cost-share, no deductible Colonoscopy, Proctosigmoidoscopy and Flexible Sigmoidoscopy (Diagnostic) allowed Durable Medical Equipment allowed 20% of Emergency Room Services Eye Exams (Routine) 1 Eye Exams (Diagnostic) Genetic Testing 1 allowed allowed allowed allowed $30 copayment 2 Home Health Care 5 No cost-share, no deductible No cost-share, no deductible Home Infusion Therapy 5 No cost-share, no deductible No cost-share, no deductible Hospice Care 5 No cost-share, no deductible No cost-share, no deductible

4 Hospitalization for Medical/Surgical Care $11/day $17.05/day ($25 min charge) 2 ($25 min charge) 2 Network Provider: Lesser of $250/day or 25% of ; plus 20% of professional fees DRG 6 Non-network Provider: Lesser of $708/day or 25% of billed ; plus 25% of professional fees Hospitalization for Behavioral Health (Not including Partial Hospitalization Programs (PHP), Residential Treatment Centers or Substance Use Disorder Treatment) $20/day ($25 min charge) 2 $40/day 2 Non-network Provider: High Volume 3 Hospital: 25% of billed or Low Volume 3 Hospital: Lesser of $208/day or 25% of billed ; plus 25% of professional fees Immunizations 1 No cost-share, no deductible No cost-share, no deductible Infectious Disease Screening 1 allowed Laboratory Services allowed 4 Mammograms (Screening) 1 No cost-share, no deductible No cost-share, no deductible Mammograms (Diagnostic) allowed $11/day ($25 min Maternity Inpatient Services $17.05/day ($25 min charge) 2 charge) 2 Network Provider: Lesser of $250/day or 25% of ; plus 20% of professional fees DRG 6 Non-network Provider: Lesser of $708/day or 25% of billed ; plus 25% of professional fees Maternity outpatient care for delivery planned in a hospital No cost-share, no deductible

5 Maternity outpatient care for delivery planned at home or other setting Maternity outpatient care for delivery planned in TRICARE authorized birthing center Medical Supplies Medication Management (Behavioral health) allowed $25 copayment 2 $25 copayment 2 Occupational Therapy allowed allowed allowed allowed 20% of Pap Smears (Screening) 1 No cost-share, no deductible No cost-share, no deductible Pap Smears (Diagnostic) allowed Partial Hospitalization Programs (PHP) Physical Therapy $20/day ($25 min charge) 2 $40/day 2 ; plus 25% of professional fees allowed

6 Prosthetic Devices allowed 20% of Psychotherapy (Outpatient mental health) allowed Individual/Family Therapy: $25 Group Therapy: $17 Psychological Testing allowed Residential Treatment Center (RTC) $20/day ($25 min charge) 2 $40/day 2 School Physicals 1 allowed Skilled Nursing Facility (SNF) Care $17.05/day ($25 min charge) 2 charge) 2 $11/day ($25 min Network Provider: Lesser of $250/day or 20% of ; plus 20% of professional fees ; plus 25% of professional fees Speech Therapy Sleep Studies allowed allowed Network Provider: 20% of contracted rate

7 Cost Chart Active Duty Family Members Retired Service Members and Their Families TRICARE Prime/ TRICARE Prime Remote/TRICARE Young Adult Prime TRICARE Standard/TRICARE Reserve Select/TRICARE Young Adult Standard TRICARE Prime/ TRICARE Young Adult Prime TRICARE Standard/TRICARE Retired Reserve/TRICARE Young Adult Standard Substance Use Disorder Treatment $20/day ($25 min charge) 2 $40/day 2 Network Provider: 20% Non-network Provider: High Volume 3 Hospital: 25% of or Low Volume 3 Hospital: Lesser of $208/ day or 25% of billed ; plus 25% of professional fees. Urgent Care allowed Well-Child Care Visits 1 No cost-share, no deductible No cost-share, no deductible X-ray Services allowed 4 ¹ Clinical preventive services are screenings or treatment with no symptoms. See the Clinical Preventive Services page for coverage details. 2 The copayment is for facility fees, there is no separate copayment for professional fees. There may be an additional cost-share for separately billed durable medical equipment (DME) or prosthetics associated with a surgical procedure (e.g., implanted devices or braces). 3 High volume means the facility has discharged 25 or more TRICARE patients, under behavioral health, 25 or more TRICARE patients, under behavioral health, 877-TRICARE. 4 - pendent laboratory or radiology facility. 5 and hepatitis B vaccines, oral cancer drugs, antiemetic drugs, orthotics, prosthetics, enteral and parenteral nutritional therapy, and drugs/biologicals administered by other than oral methods are services that can be paid in addition to the prospective payment amount subject to applicable copayment/ cost-sharing and deductible amounts. 6 directly. Providers can contact 877-TRICARE. An Important Note about TRICARE Cost Information Changes to TRICARE programs are continually made as public law and/or federal regulation are amended. The preceding information is provided to help you better understand what Tricare items may have out-of-pocket expenses. For complete details contact your Tricare representative at TRICARE is a registered trade mark of TRICARE Management Activity. All rights reserved. PF0511x029x1211

8 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS While many Veterans qualify for free healthcare services based on a VA compensable service-connected condition or other qualifying factor, most Veterans are asked to complete an annual financial assessment, to determine if they qualify for free services. Veterans whose income exceeds the established VA Income Thresholds, as well as those who choose not to complete the financial assessment, must agree to pay required copays to become eligible for VA healthcare services. Copays Primary Care Services: $15 Specialty Care Services: $50 Prescriptions: 30-day or less supply for certain Veterans: $8 30-day or less supply for higher income Veterans: $9 There are two inpatient copay rates, the full rate and the reduced rate. Priority Group 7 and certain other Veterans are responsible for paying 20 percent of VA's inpatient copay rate. Inpatient Copay for the first 90 days of care during a 365-day period $ Inpatient Copay for each additional 90 days of care during a 365-day period $ Daily Charge.. $2/day Priority Group 8 and certain other Veterans are responsible for VA's full inpatient copay rate. Inpatient Copay for the first 90 days of care during a 365-day period.. $1,156 Inpatient Copay for each additional 90 days of care during a 365-day period.$578 Daily Charge. $10/day Veterans living in high cost areas may qualify for a reduced inpatient copay rate. For more information contact VA toll-free at VETS (8387). Long term care copays are based on three levels of care: Inpatient: Up to $97 per day (Community Living (Nursing home), Respite, Geriatric Evaluation) Outpatient: $15 per day (Adult Day Health Care, Respite, Geriatric Evaluation) Domiciliary: $5 per day Actual copay will vary based on Veteran s current financial assessment.

9 Some Veterans qualify for free healthcare and/or prescriptions based on special eligibility factors including but not limited to: Former Prisoner of War status 50% or more compensable VA service-connected disabilities (0-40% compensable serviceconnected may take copay test to determine prescription copay status) Veterans deemed catastrophically disabled by a VA provider Special registry examinations offered by VA to evaluate possible health risks associated with military service Counseling and care for military sexual trauma Compensation and Pension examinations Care that is part of a VA research project Care related to a VA-rated service-connected disability Readjustment counseling and related mental health services Care for cancer of head or neck caused by nose or throat radium treatments received while in the military Individual or Group Smoking Cessation or Weight Reduction services Publicly announced VA public health initiatives, for example, health fairs Care potentially related to combat service for Veterans that served in a theater of combat operations after November 11, 1998 Laboratory and electrocardiograms Hospice care The preceding information is provided to help you better understand what VA items may have out-of-pocket expenses. For complete details contact your VA representative at or visit their website at

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