| CARE REQUIRED |
TRICARE EXTRA/STANDARD PAYS |
YOUR TRICARE EXTRA/STANDARD SUPPLEMENT
PAYS |
| Inpatient care in civilian hospitals for
RETIREES and
dependant family members (room, board, supplies and staff services
billed by the hospital). |
The Tricare
Standard/DRG amount (contracted rate for Tricare Extra) minus your cost share. |
The lesser of
$535/day or
25% of billed amount, not to exceed the Tricare Standard DRG amount
(lesser of $250/day or 25% cost share** of the contracted rate for Tricare Extra) PLUS
100% of covered excess charges up to the legal limit
community standard level. (After you satisfy the fiscal year plan
deductible.) |
| Inpatient care in civilian
hospitals for RETIREES and dependent family members (doctors, and other
inpatient services not billed by the hospital). |
75% of the
Tricare Standard allowed amount (80% for Tricare Extra) for doctors
and other [professional services. |
Your cost share PLUS
100% of eligible charges up to the legal limit community
standard level. |
| Inpatient care in military
hospitals. |
All but the daily subsistence
fee. |
The
daily subsistence fee. |
| Outpatient care for
RETIREES and dependent family members (office visits, clinics, lab,
prescription drugs, etc.) |
75% of the
Tricare Standard allowed amount (80% for Tricare Extra) after you pay
the Tricare Outpatient Deductible . |
Your cost share PLUS
100% of eligible charges up to the legal limit community
standard level, AFTER you pay the fiscal year plan deductible of $150
per person, $300 family maximum. |
| Inpatient care
in civilian hospitals for ACTIVE DUTY dependents.
|
All allowable
charges except daily subsistence fee or $25, whichever is greater.
|
Active
Duty Plan - $25 or the daily subsistence fee, whichever is
greater, PLUS
100% of covered excess charges up to the reasonable and customary
community standard level. |
| Outpatient care
for ACTIVE DUTY dependents (office visits, clinics, lab, prescription
drugs, etc.)
|
80% of the Tricare Standard allowed
amount (85% for Tricare Extra) after you pay the Tricare Outpatient Deductible.
|
Active
Duty Plan - Your cost share PLUS
100% of covered excess charges up to the reasonable and customary
community standard level, AFTER you pay the Tricare Extra Standard
Outpatient Deductible.* |