| Care Required |
Tricare Extra/
Standard Pays |
Your Tricare Extra/Standard 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) PLUS 100% of covered excess charges up to the reasonable and customary community standard level.
(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 cost share PLUS 100% of covered excess charges up to the reasonable and customary community standard level.
|
| 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 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 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 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.* |
