Free Guide to Understanding TRICARE Coverage Options

What TRICARE Is and How It Works

TRICARE is the health insurance program for military service members, retirees, and their families. It covers active duty personnel, National Guard members, Reserve members, retired service members, survivors, and former spouses in some cases. The program serves approximately 9.4 million beneficiaries worldwide.

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The Defense Health Agency runs TRICARE. It is not the same as the VA (Veterans Affairs), though many people confuse the two. TRICARE covers current military personnel and their dependents, while the VA serves veterans after they leave the military. Some people may be covered by both programs, but they work differently.

TRICARE operates through a network of military treatment facilities (hospitals and clinics on military bases) and civilian doctors and hospitals. When you use TRICARE, you can receive care at either location. The program uses a cost-sharing model, meaning both TRICARE and the beneficiary pay part of the costs. How much each party pays depends on which TRICARE plan you use and what type of care you receive.

The program has been around since 1995, when it replaced an older system called CHAMPUS. TRICARE has grown and changed over the years to serve more people and offer more options. Today, it is the largest military health insurance program in the world.

TRICARE works with private insurance companies called health plans. These companies help process claims, manage networks of doctors, and handle billing. However, TRICARE itself is a federal program, not a private insurance company.

Practical Takeaway: Understanding that TRICARE is a federal military health insurance program—separate from the VA and different from civilian insurance—helps you know where to find information about your coverage and how to use your benefits.

Understanding the Main TRICARE Plans

TRICARE offers several different plans. The main plans are TRICARE Prime, TRICARE Select, TRICARE for Life, and TRICARE Young Adult. Each plan has different rules about which doctors you can see, how much you pay, and what services are covered. Choosing the right plan depends on your military status, age, location, and healthcare needs.

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TRICARE Prime is similar to an HMO (Health Maintenance Organization). Members choose a primary care manager—usually a doctor at a military hospital or clinic—who coordinates all their care. With TRICARE Prime, you pay a monthly fee and lower copayments when you see doctors. Most care must be received through military treatment facilities or the TRICARE Prime network. If you use an out-of-network doctor without a referral, you pay much more. Approximately 2.2 million active duty family members use TRICARE Prime.

TRICARE Select is similar to a PPO (Preferred Provider Organization). There is no monthly fee, but copayments are higher than TRICARE Prime. You do not have to choose a primary care manager. You can see any doctor in the TRICARE Select network without a referral. If you use an out-of-network doctor, you pay more, but you can still receive some coverage. This plan offers more flexibility than TRICARE Prime but typically costs more per visit.

TRICARE for Life covers beneficiaries age 65 and older who are also covered by Medicare. With this plan, Medicare is the primary insurance, and TRICARE for Life provides supplemental coverage. Most beneficiaries pay no additional monthly premium for TRICARE for Life after they enroll in Medicare Part B.

TRICARE Young Adult is for dependent children of military members who age out of TRICARE coverage (usually at age 21, or 23 if enrolled full-time in college). This plan allows young adults to buy coverage until age 26. As of 2023, the monthly premium is around $290 to $312 depending on the plan selected.

Practical Takeaway: Reading descriptions of each TRICARE plan and comparing copayments, networks, and rules helps you understand which plan may fit your situation and healthcare needs.

TRICARE Costs and Out-of-Pocket Expenses

TRICARE beneficiaries pay different amounts depending on their military status and which plan they choose. Active duty service members and their families typically pay less than retirees. Understanding the cost structure helps you budget for healthcare expenses and compare plans.

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With TRICARE Prime, active duty family members pay approximately $14 per month in 2024. Retirees and their families pay about $308 per month for individuals and $616 per month for families. Copayments for office visits are $0 for active duty family members and $15 to $25 for retirees, depending on the type of provider. Emergency room visits and urgent care visits also have different copayment amounts.

TRICARE Select has no monthly premium, but copayments are higher. Active duty family members pay $29 for a primary care visit and $61 for a specialist visit at a network provider. Retirees pay $38 for a primary care visit and $76 for a specialist visit. If you use an out-of-network provider, costs are significantly higher—often $59 and $137, respectively, for the same visits.

Beyond copayments, TRICARE beneficiaries may have an annual deductible. For TRICARE Select, the deductible for individuals is $50 and for families is $100. Once you meet the deductible, you pay only the copayment amounts. TRICARE Prime does not have a deductible.

Some services are covered with no copayment at all. These include preventive care visits, such as annual physical exams and certain screening tests. Prescription medications have different costs depending on whether the drug is generic, brand-name, or specialty. Generic medications cost $0 to $11 at military pharmacies and $11 to $15 at retail pharmacies.

TRICARE also has an out-of-pocket maximum. Once you spend a certain amount on copayments and deductibles in a year, TRICARE covers the rest at no additional cost. For active duty family members, the out-of-pocket maximum is $1,000 for individuals and $2,000 for families. For retirees, it is higher—$6,500 for individuals and $13,000 for families.

Practical Takeaway: Learning about copayments, deductibles, and out-of-pocket maximums for each plan helps you calculate your expected healthcare costs and choose the plan that best fits your budget.

What Services and Medications TRICARE Covers

TRICARE covers a wide range of medical services, including doctor visits, hospital stays, surgical procedures, prescription medications, mental health services, dental care, vision care, and maternity care. However, not all services are covered to the same degree, and some services may not be covered at all. Understanding what is included helps you plan for your healthcare needs.

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Primary and specialist care visits are covered for both preventive and treatment purposes. Preventive services—such as annual physical exams, blood pressure checks, and cancer screenings—are covered with no copayment. Treatment for conditions like diabetes, high blood pressure, and heart disease is also covered. However, the copayment amount depends on your plan and military status.

Hospital stays are covered, including the room, meals, nursing care, and medications given during your stay. Surgery and other inpatient procedures are covered. Outpatient procedures, such as same-day surgeries, are also covered. After you meet your deductible, you typically pay a copayment or coinsurance (a percentage of the cost) for these services.

TRICARE covers prescription medications, but the copayment depends on the medication type and where you fill the prescription. Military pharmacies have the lowest copayments. The TRICARE retail pharmacy network has slightly higher copayments. Mail-order pharmacies typically offer lower costs for long-term medications. As of 2024, generic medications at military pharmacies cost $0 to $11, brand-name medications on the formulary cost $24 to $50, and specialty medications cost $50 to $250. These amounts are higher at retail and mail-order pharmacies.

Mental health services, including therapy and psychiatry, are covered. Substance abuse treatment, including inpatient rehabilitation programs, is covered. Maternity and newborn care, including prenatal visits, delivery, and postpartum care, are covered with no