TRICARE Reserve Select Supplement Insurance Plan - How The TRICARE Select Supplement Insurance Plan Works

TRICARE Reserve Select Supplement
Insurance Plan

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How the TRICARE Reserve Select
Supplement Insurance Plan Works

Care Required	TRICARE Reserve Select Pays(1)	TRICARE Reserve Select Supplement Plan Pays
Government Hospital	All TRICARE Reserve Select Allowed Amount except the Daily Subsistence Fee	Current Daily Subsistence Charge
Civilian Hospital or Skilled Nursing Facility	All TRICARE Reserve Select Allowed Amount except the Daily Subsistence Fee or $25, whichever is greater	The greater of: 1) Current Daily Subsistence Charge for each day of confinement(b); or 2) $25.00 for all Confinements which are due to the same or related Sickness or Injury and separated by less than 60 days; until the TRICARE Cap(b) is met;
Outpatient(d) Visit	TRICARE Network Provider 85% of the TRICARE allowable charge after the annual deductible(c) is met TRICARE Authorized Non-Network Provider 80% of the TRICARE allowable charge after the annual deductible(c) is met	TRICARE Network Provider Your 15% cost share for covered expenses until the TRICARE Cap is met TRICARE Authorized Non-Network Provider Your 20% cost share PLUS 100% of the Covered Excess Charges up to the Legal Limit(e)
Prescription Drug Charges(f)	Home Delivery: All but the copayments of $7 generic, $24 brand name, or $53 non-formulary Network Retail (up to 30-day supply): All but the copayments of $11 generic, $28 brand name, or $53 non-formulary	Home Delivery: Copayments of $7 generic, $24 brand name, or $53 non-formulary Network Retail (up to 30-day supply): Copayments of $11 generic, $28 brand name, or $53 non-formulary
Non-Network Pharmacy(f)	All but $24 or 20% of the total cost for generic/brand name or $50 or 20% for non-formulary (whichever is greater) after the fiscal year deductible	Copayments of $28 or 20% of the total cost for generic/brand name or $53 or 20% for non-formulary (whichever is greater) after the fiscal year deductible

(a) Confinement or confined means being an inpatient in a hospital (or skilled nursing facility) due to sickness or injury. And skilled nursing facility does not mean: a) a hospital; or b) a place for rest, custodial care, or the aged; or c) a place for the treatment of mental disease, drug addicts or alcoholics.

(b) TRICARE Catastrophic Cap-Maximum out-of-pocket expense=$1,000 per family, per fiscal year. Monthly premium payments do not apply toward meeting the Catastrophic Cap.

(c) The TRICARE Reserve Select Supplement Insurance Plan will not pay for expenses used to satisfy the annual deductible charged by TRICARE. TRICARE Annual Outpatient Deductible:

Member-Only Family
E-4 and Below: $50.00 $100.00

E-5 and Above: $150.00 $300.00

(d) All outpatient Covered Expenses will be deemed incurred on the date the Covered Person received the treatment, service or supply that gave rise to the expense.

(e) Legal Limit means the maximum amount that a non-participating provider can legally charge. This amount is up to the 115% of the TRICARE Allowed Amount.

(f) Check with TRICARE to confirm your actual copay portion. TRICARE’s portion of coverage is provided here for your convenience, but is subject to change by DHA (Defense Health Agency). The Supplement Insurance reimburses for copay costs for covered services after deductibles have been met.