When it comes to healthcare costs, “copay,” “co-pay,” and “deductible” are terms you may hear often. But what do these terms mean and how might they affect you?
Co-payments, co-pays, and annual deductibles are types of out-of-pocket expenses you may pay to get covered health care services and prescription drugs.
- A tickets it’s a fixed dollar amount you pay for a health service or drug.
- A cost sharing it is the percentage of the total cost of a paid health service or drug. Co-pays typically apply when you use an out-of-network provider or TRICARE-authorized out-of-network pharmacy and you have met your annual deductible.
- A annual deductible it is the amount you paid for health care services and drugs each calendar year before cost sharing began.
Tickets, co-payments and the annual deductible depend on a few factors:
“Knowing how these factors affect what you’ll pay can help you choose the most cost-effective option for getting care,” said Shane Pham, program analyst in the TRICARE Health Plan Policies and Programs Section at the Defense Health Agency. “And if you’re eligible to enroll in or change your health plan during TRICARE’s open season or after a qualifying life event, understanding costs can help you choose the best plan for your needs.”
In general, you will have lower out-of-pocket costs when:
Read on to learn more about your plan’s co-payments, co-payments and deductibles, and how out-of-pocket prescription costs work.
TRICARE Prime options
Active Service Members (ADSMs) do not pay co-pays and co-pays for covered health services. Active duty family members and transient survivors are also not enrolled in a TRICARE Prime option.
Retirees, their family members, and all other TRICARE Prime members pay copays for covered health care visits.
TRICARE Prime plans do not have annual deductibles. But if you use the point of service (POS) option, you will have an annual POS deductible. The POS option refers to non-emergency care received without a prescription. When you use this option, you will pay the full cost of support up to the POS excess, as indicated in TRICARE Costs and Fees Fact Sheet. After that, you’ll pay 50% of the TRICARE-allowed rate when you use the POS option.
TRICARE Select and TRICARE premium plans
You have an annual deductible if you are enrolled in one of these plans:
If you’re subscribed to one of these plans, tickets and cost sharing are based on the type of provider you see:
- When you see a TRICARE Authorized Network Provider, you will pay a fee.
- If you use a TRICARE-authorized non-network provider, you will pay a cost share once you reach your annual deductible.
TRICARE For Life
If you have TRICARE For Life, you have a TRICARE deductible and cost sharing if you get services not covered by Medicare. To learn more, see “Have questions about TRICARE for Costs of Living? Find the answers here.”
TRICARE Pharmacy Program
Co-payments and co-pays for prescription drugs depend on who you are and where you fill your prescription. ADSMs pay nothing out of pocket for prescription drugs. All other types of beneficiaries pay copays for drugs from TRICARE pharmacy home delivery and TRICARE retail network pharmacies. There are no co-payments for prescriptions filled at military pharmacies.
If you get a prescription from an out-of-network pharmacy, you will pay the full cost of the drug upfront. You can then submit a refund request. Applicable fees, co-pays and deductibles may apply.
How to find out your out-of-pocket expenses
Tickets, co-pays, and deductibles are subject to change each year of the plan. To find costs for the current year, check the Compare Costs tool and the TRICARE Costs and Fees Fact Sheet.
To learn more about out-of-pocket costs, go to TRICARE Cost Terms. And if you have any questions, contact your regional TRICARE contractor.
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