AUGUST 30, 2023 – When it comes to health care costs, “copayment,” “cost-share,” and “deductible” are terms you might hear a lot. But what do these terms mean, and how might they affect you?
Copayments, cost-shares, and annual deductibles are types of out-of-pocket costs you may pay to get covered health services and prescription drugs.
- A copayment is a fixed dollar amount you pay for a health care service or drug.
- A cost-share is the percentage of the total cost of a health care service or drug that you pay. Cost-shares typically apply when you use a TRICARE-authorized non-network provider or a non-network pharmacy and you’ve met your annual deductible.
- An annual deductible is the amount you pay for health services and drugs each calendar year before cost-sharing starts.
Your copayments, cost-shares, and annual deductible depend on a few factors:
- Your TRICARE plan
- Your beneficiary category
- Your beneficiary group
- The type of service you get
- Who provides the service
“Knowing how these factors affect what you’ll pay can help you choose the most cost-effective option for getting care,” said Shane Pham, program analyst with TRICARE Health Plan’s Policy and Programs Section at the Defense Health Agency. “And if you’re eligible to enroll in or change your health plan during TRICARE Open Season or after a Qualifying Life Event, understanding costs can help you choose the best plan for your needs.”
Generally, you’ll have lower out-of-pocket costs when:
- You follow your plan’s rules for getting care.
- You see a TRICARE network provider instead of a non-network provider when you get civilian care.
Read on to learn more about your plan’s copayments, cost-shares, and deductible and how out-of-pocket costs work for prescriptions.
TRICARE Prime options
Active duty service members (ADSMs) don’t pay copayments and cost-shares for covered health services. Neither do active duty family members and transitional survivors enrolled in a TRICARE Prime option.
Retirees, their family members, and all others enrolled in TRICARE Prime pay copayments for covered health care visits.
TRICARE Prime plans don’t have annual deductibles. But if you use the point-of-service (POS) option, you’ll have an annual POS deductible. The POS option refers to nonemergency care you get without a referral. When you use this option, you’ll pay the full cost of care until you meet your POS deductible, as outlined in the TRICARE Costs and Fees Fact Sheet. After that, you’ll pay 50% of the TRICARE-allowable charge when you use the POS option.
TRICARE Select and TRICARE premium-based plans
You have an annual deductible if you’re enrolled in any of these plans:
- TRICARE Select
- TRICARE Select Overseas
- TRICARE Reserve Select
- TRICARE Retired Reserve
- TRICARE Young Adult Select
- Continued Health Care Benefit Program
If you’re enrolled in one of these plans, copayments and cost-shares are based on the type of provider you see:
- When you see a TRICARE-authorized network provider, you’ll pay a copayment.
- If you see a TRICARE-authorized non-network provider, you’ll pay a cost-share after you meet your annual deductible.
TRICARE For Life
If you have TRICARE For Life (TFL), you have a TRICARE deductible and cost-shares if you get services not covered by Medicare. To learn more, check out “Have TRICARE For Life Costs Questions? Find Answers Here.”
TRICARE Pharmacy Program
Copayments and cost-shares for prescription drugs are based on who you are and where you fill your prescription. ADSMs pay nothing out of pocket for prescription drugs. All other beneficiary types pay copayments for drugs from TRICARE Pharmacy Home Delivery and TRICARE retail network pharmacies. There are no copayments for prescriptions filled at military pharmacies.
If you get a prescription from a non-network pharmacy, you’ll pay the full cost of the drug up front. Then you can file a claim for reimbursement. Applicable copayments, cost-shares, and deductibles may apply.
How To Find Out-of-Pocket Costs
Copayments, cost-shares, and deductibles are subject to change each plan year. To find costs for the current year, check the Compare Costs tool and the TRICARE Costs and Fees Fact Sheet.
To learn more about out-of-pocket costs, go to TRICARE Cost Terms. And if you have questions, reach out to your TRICARE regional contractor.
Would you like the latest TRICARE news sent to you by email? Visit TRICARE Subscriptions, and create your personalized profile to get benefit updates, news, and more.
Courtesy Story
Defense Health Agency