| Care Required |
Tricare Extra/
Standard Pays |
Your Tricare Extra/Standard Supplement
Pays |
| Inpatient care 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. |
Comprehensive Plan & High Option II Plan - The lesser of $459/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) PLUS 100% of
covered excess charges up to the reasonable and customary community standard level.
(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. |
Comprehensive Plan & High Option II Plan - Your cost share** PLUS 100%
of covered excess charges up to the reasonable and customary community standard level.
|
| Inpatient care in military hospitals. |
All but the daily subsistence fee. |
All Plans - 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. |
Comprehensive Plan - After you satisfy the fiscal year plan deductible of $75 per person,
and $150 family maximum, the plan will reimburse you (1) the Tricare fiscal year outpatient deductible
of $150 per person and $300 family maximum,* (2) your cost share** and (3) 100% of covered excess
charges up to the reasonable and customary community standard level.
High Option II Plan - Your cost share** PLUS 100% of covered excess charges up to
the reasonable and customary community level, AFTER you pay the fiscal year plan deductible of
$150 per person, $300 family maximum.*
|
Inpatient care 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 reasonable and customary
community standard level.
Active Duty Plan - Your cost share** PLUS 100% of covered excess charges
up to the reasonable and customary community standard level, AFTER you pay the
Tricare Extra/Standard Outpatient Deductible.* |
