| CARE REQUIRED |
TRICARE STANDARD/EXTRA PAYS |
YOUR
TRICARE STANDARD/EXTRA 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 the DRG/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) 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
AFTER you satisfy the fiscal year Plan Deductible. |
| 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 AFTER you satisfy the
fiscal year plan deductible PLUS 100% of covered excess charges up
to the TRICARE Legal Limit.
For prescription drugs - the plan pays your copayment
amounts. |
| 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. |
| 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 TRICARE Legal Limit.
For prescription drugs - the plan pays your copayment
amounts. |
