| Care Required |
TRICARE Standard/
Extra Pays |
Your TRICARE Standard/Extra Supplement High Option II Plan
Pays |
| Inpatient confinement in civilian hospitals for RETIREES and dependent 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)
(After you satisfy the fiscal year plan deductible.)
|
| Inpatient confinement 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 25% Standard/20% Extra cost share PLUS 100% of Covered Excess Charges up to the Legal Limit**.
|
| Inpatient confinement 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 25% Standard/20% Extra cost share AFTER you satisfy the fiscal year plan
deductible PLUS 100% of Covered Excess Charges up to the Legal Limit**.
|
Inpatient confinement in civilian hospitals for ACTIVE DUTY
dependents
Outpatient care for ACTIVE DUTY dependents (office visits, clinics, labs, prescription drugs, etc.) |
All allowable charges except daily subsistence fee or $25, whichever is greater.
80% of the TRICARE Standard
allowed amount (85% for TRICARE Extra) after you pay the TRICARE Outpatient Deductible. |
Active Duty Plan - $25 or the daily subsistence fee, whichever is greater, PLUS 100% of Covered Excess Charges up to
the Legal Limit.
Active Duty Plan - Your cost share PLUS 100% of Covered Excess Charges up to the Legal Limit.** |
