§1075a Tricare Prime: Cost Sharing

Summary

Sets how much people in TRICARE Prime must pay out of pocket for care and when they pay nothing. People covered under 1074(a) pay nothing. If a service member first enlisted or was appointed on or after January 1, 2018, or is a dependent of that person, their TRICARE Prime fees for calendar year 2018 are listed here and change later with cost-of-living increases: active‑duty family members pay $0 for enrollment, no deductible, $1,000 annual cap, and $0 for most visits and services; retired beneficiaries pay $350 per individual or $700 per family to enroll, no deductible, $3,500 annual cap, $20 primary‑care visits and $30 specialty visits, $60 ER, $30 urgent care, $60 ambulatory surgery, $40 ground ambulance, durable medical equipment at 20% of the negotiated fee, $150 per inpatient admission, and $30 per day for inpatient skilled nursing/rehab. People who first enlisted before January 1, 2018 (or their dependents) follow the program’s other rules and not this table. All fixed dollar amounts are adjusted each year by the same percent retired pay goes up under section 1401a, rounded down to the nearest $1 with any leftover carried forward. Enrollment fees, deductibles, and caps apply by calendar year. The Secretary sets charges for services not listed. If a TRICARE Prime patient gets care without a required referral, they pay 50% of the allowed point‑of‑service charge. Any FDA‑approved or cleared contraceptive method, related care (including insertion, removal, follow up), sterilization, and counseling provided under TRICARE Prime have $0 cost to the beneficiary (see 21 U.S.C. 355, 360(k), 360c(f)(2), 360e). The Secretary may waive charges for the first three outpatient mental‑health visits each year for active‑duty family members; that waiver authority ends five years after enactment of the National Defense Authorization Act for Fiscal Year 2024.