Tricare benefits vary significantly from plan to plan, and costs will be subject to specific health plan rules that also vary widely. Tricare coverage is often accompanied with some type of copayment or cost-share for both medical services and prescriptions. Tricare prescription coverage is handled at military pharmacies, through network and non-network pharmacies as well as by home delivery. Additional benefits for mental health coverage or physical disabilities are available in the form of supplemental health service plans that come attached to cost-share fees which are only applicable in the months in which the supplemental services are used.
The question “What does Tricare cover?” is often aimed at understanding how to use non-network providers and Tricare does offer a Point-of-Service Option for that purpose. While fees may increase for services such as the Point-of-Service Option and other supplemental assistance, health coverage through Tricare is comprehensive and market-competitive.
How does TRICARE insurance handle copayments and cost-shares?
Tricare benefits for Active Duty sponsors have no associated copayments or cost-shares and never pay out of pocket for any type of medical care. Tricare coverage for dependents utilizing a Prime plan may come with copayments or cost-shares if the member is using Tricare Select, is using Tricare Home Delivery or is seeking care without a referral. Apart from a minimal per diem when receiving inpatient care, there is no expense associated with health services received at any Military Treatment Facility (MTF). Tricare spouse coverage is also determined by whether the sponsor entered uniformed service before or after January 1, 2018. Those that entered before are labeled in the cost category called “Group A” and those that entered afterward are labeled as “Group B.”
Tricare coverage does offer an Extended Health Care Option (ECHO) to meet the unique needs of members with additional health concerns. While there is no enrollment fee to participate in Tricare ECHO, members are expected to pay a portion of the monthly expenses for ECHO benefits. The monthly cost-share for ECHO benefits will be determined by the sponsor’s pay grade and is applied as a single fee to the sponsor, not as one fee per ECHO beneficiary. If benefits from Tricare ECHO are not used in a calendar month, the sponsor pays no cost-share fees for that month.
Does TRICARE payment include prescription coverage?
Tricare coverage under any plan typically extends to all necessary prescriptions. Tricare covered prescriptions are handled by a pharmacy contractor called Express Scripts and include any prescription that can meet the following requirements:
- A drug not considered a part of a procedure that is covered under a Tricare medical benefit
- A drug that is FDA-approved
- A drug that is prescribed in good faith and by an official medical practitioner representing high standards of quality
Some Tricare benefits include full payment for prescriptions and others require a copayment. Tricare copay requirements can be reviewed in the benefit packet of any given Tricare health plan or by accessing the Tricare Formulary Search tool on the Express Scripts homepage. Tricare requires some prescriptions to receive prior authorization in order for them to be covered and utilizes an official formulary to establish the copay that will be expected for any given drug. To find out more about prescriptions covered by Tricare, download our free and informative guide.
What dental costs does TRICARE cover?
Tricare benefits associated with dental health are separate from those offered for other medical services. Tricare payment for a health plan does not include dental services and sponsors must purchase a Tricare dental plan independently from their other Tricare health coverage. Much of access to Tricare dental coverage is determined by who you are. Active Duty sponsors are covered via their active duty dental benefits and will have most of their dental needs met at military dental clinics. Active Duty, National Guard/Reserve and Survivor family members are able to purchase the Tricare Dental Program to cover:
- Dental exams, cleanings, fillings.
- Root canals.
- Oral and gum surgeries, extractions.
- Dentures and crowns.
- Orthodontics and braces.
Dental benefits through Tricare also exist for retired service members of all kinds through the Tricare Retiree Dental Program. For National Guard/Reserve sponsors, availability and source of coverage will depend on whether you are active or not, and monthly premiums will be based on your military status.
What TRICARE cost is associated with the Point-of-Service Option?
Tricare billing may increase at any time that a Tricare Prime member chooses the Point-of-Service Option without following the referral requirements or receives health services from a non-network provider without obtaining prior authorization from the Tricare regional contractor. Recipients of Tricare coverage through the Point-of-Service Option pay higher out-of-pocket costs but can visit any authorized Tricare provider without a referral. When exercising this option, beneficiaries will pay an established Point-of-Service fee instead of the traditional Tricare copayment and will also be responsible for paying any other non-network fees implemented by the service provider. An outpatient deductible also applies before cost-sharing begins through this option.
What is the TRICARE fee schedule?
Tricare cost varies significantly between plans and contingent on whether you fall into Group A or Group B. Most Tricare payment structures do not include an annual enrollment fee, but some group subsets are subject to annual deductibles. Covered services are broken down not just by type, but also by whether they apply to the plan sponsor or to an associated beneficiary. Typical cost breakdowns include specific fees for:
- Emergency room visits.
- Preventive care visits.
- Primary care outpatient visits.
- Urgent care center visits.
- Specialty care outpatient visits.
- Inpatient admission.
The Tricare fee schedule likewise differentiates pharmacy expenses based on whether they are incurred at a military pharmacy, by home delivery, by a Tricare-affiliated network pharmacy or via a non-network pharmacy. Monthly premium rates can also be affected by the region in which services are rendered or military duty is being performed by the sponsor.
Can I pay for TRICARE online?
Tricare payment options, once the first payment is made, are available in multiple different formats. You can pay Tricare online, through allotments, via electronic funds transfers or with a debit or credit card. Payment options vary by dental and medical program, so it is important to review your benefits package to know what applies to any given plan.
Tricare routinely issues Explanation of Benefits (EOB) statements to help guide your understanding of the benefits coverage you have received, and any itinerant cost-shares or copayments associated with your Tricare benefits.
For more detailed information on Tricare premiums, download our comprehensive guide today.