| 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 |