2021 Retirees and Their Family Members Costs (Group A)
Note: Visit our Copayment and Cost-Share Information page for 2022 costs.
View the cost information below for retirees and their family members (not including TRICARE Young Adult) with sponsors who enlisted before Jan. 1, 2018.
| |
TRICARE Prime |
TRICARE Select |
|---|
| Enrollment Fees |
$303/individual, $606/family
(annually) |
$150/individual, $300/family
(annually) |
| Annual Deductibles |
$0 |
$150/individual, $300/family |
| Catastrophic Cap |
$3,000 per calendar year |
$3,500 per calendar year |
Note: Point of Service cost-shares and deductibles may apply to TRICARE Prime and TRICARE Prime Remote beneficiaries.
Annual deductibles apply to outpatient services only.
| Type of Care |
TRICARE Prime |
TRICARE Select |
|---|
| Ambulance - Outpatient |
$42 |
Network Provider: $93
Non-Network Provider: 25% |
| Ambulance - Inpatient |
25% |
Network Provider: 25%
Non-Network Provider: 25% |
| Ambulatory Surgery |
$63 |
Network Provider: 20%
Non-Network Provider: 25% |
| Ancillary Services |
$0 |
Network Provider: $0
Non-Network Provider: 25% |
| Durable Medical Equipment |
20% |
Network Provider: 20%
Non-Network Provider: 25% |
| Emergency Room |
$63 |
Network Provider: $125
Non-Network Provider: 25% |
| Home Health Care |
$0* |
$0* |
| Hospice Care |
$0 |
$0 |
| Hospitalization (includes mental health) |
$158 per admission |
Network Provider: Lesser of $250 per day or 25% of billed charges, plus 20% of professional fees
Non-Network Provider: Lesser of $1,034 per day or 25% of billed charges, plus 25% of professional fees |
| Laboratory and X-Rays |
$0 |
Network Provider: $0
Non-Network Provider: 25% |
| Maternity Care - Inpatient Delivery Setting |
$158 per admission |
Network Provider: Lesser of $250 per day or 25% of billed charges,
plus 20% of professional fees
Non-Network Provider: Lesser of $953 per day or 25% of billed charges, plus 25% of professional fees |
| Office Visits - Primary Care |
$21 |
Network Provider: $30
Non-Network Provider: 25% |
| Office Visits - Specialty Care |
$31 |
Network Provider: $46
Non-Network Provider: 25% |
| Outpatient Mental Health Visits |
$31 |
Network Provider: $46
Non-Network Provider: 25% |
| Partial Hospitalization |
$31 per day** |
Network Provider: $46**
Non-Network Provider: 25% |
| Preventive Services - Eye Examinations |
$0 |
Not a covered benefit |
| Preventive Services - All Other Covered Services |
$0 |
$0 |
| Residential Treatment Center |
$30 per day |
Network Provider: Lesser of $250 per day or 25% of billed charges,
plus 20% of professional fees
Non-Network Provider: Lesser of $953 per day or 25% of billed charges, plus 25% of professional fees |
| Skilled Nursing Facility |
$31 per day |
Network Provider: Lesser of $250 per day or 25% of billed charges,
plus 20% of professional fees
Non-Network Provider: 25% of allowable charges |
| Urgent Care Services |
$31 |
Network Provider: $30
Non-Network Provider: 25% |
*Costs may apply for durable medical equipment (DME) and medications/drugs.
**Copayment information is calculated per day for partial hospitalization programs and intensive outpatient treatment. Opioid treatment program services copayment is applied on a weekly basis.
