TRICARE Compumedic & CMAC Rates Guide 2026
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## Quick answer "Compumedic.htm" refers to the legacy technical filename for the **TRICARE Allowable Charge (CMAC)** database and the associated "Check TRICARE Rates" calculation tool. It is the primary system used by providers and beneficiaries to determine the maximum amount TRICARE will pay for specific medical procedures and services.
In detail
The term "Compumedic" is often associated with the underlying software logic that the Defense Health Agency (DHA) uses to calculate geographic-specific rates for medical services. While the ".htm" extension is part of the legacy web architecture, the system itself governs how Billable Services (identified by CPT or HCPCS codes) are converted into the **Champus Maximum Allowable Charge (CMAC)**.
### How the Rate System Works TRICARE does not pay whatever a doctor bills. Instead, it uses a formula based on: * **The Procedure Code:** Usually a 5-digit CPT code. * **The Geographic Location:** Rates are adjusted based on the cost of practicing medicine in your specific ZIP code. * **Provider Type:** Specialists, general practitioners, and non-physician providers (like Nurse Practitioners) may have different allowable rates.
### 2026 Region Refresh As of 2026, these rates are managed by two primary regional contractors under the T-5 contract: * **East Region:** Humana Military. * **West Region:** TriWest Healthcare Alliance.
Regardless of the contractor, the "Compumedic" data (CMAC rates) remains the federal standard across both regions.
### Key Components of TRICARE Rates | Feature | Description | | :--- | :--- | | **CMAC** | The maximum dollar amount TRICARE will pay for a specific service. | | **Balance Billing** | If you see a non-participating provider, they can charge up to 15% above the CMAC (the "allowable charge"). | | **Geographic Adjustment** | A procedure in New York City will have a higher allowable charge than the same procedure in rural Mississippi. |
Who this applies to
* **Active Duty Service Members (ADSMs):** While ADSMs generally have $0 out-of-pocket costs, the allowable charge determines what the government pays the civilian network provider. * **TRICARE Select Beneficiaries:** This is critical for you. If you see a "Non-Network, Non-Participating" provider, you are responsible for the difference between the provider’s bill and the CMAC rate. * **Medical Providers:** Doctors use the "Compumedic" rate files to understand their reimbursement schedule for the 2026 plan year. * **TRICARE For Life (TFL) Users:** When Medicare is the primary payer, TRICARE acts as a second payer based on these allowable charge limits.
Common scenarios
### Scenario 1: The Non-Participating Specialist Jane is on TRICARE Select in the West Region (TriWest). She visits a specialist who does not participate in TRICARE. The specialist bills $500 for a consultation. The CMAC (Compumedic rate) for that ZIP code in 2026 is $300. * **TRICARE pays:** Its share of the $300. * **Jane pays:** Her cost-share PLUS the "balance bill" of up to 15% of the $300 ($45). * **Total Billing:** Jane is protected from the full $500, but she must pay more than if she saw a network provider.
### Scenario 2: Standard Network Office Visit Mark visits a network doctor for an immunization. The doctor bills $150. The 2026 CMAC rate is $95. * **Result:** Because the doctor is in-network, they must accept the $95 as payment in full. They cannot bill Mark for the remaining $55.
Related terms
* **CMAC (Champus Maximum Allowable Charge):** The specific dollar amount TRICARE sets as the maximum ceiling for a procedure. * **CPT Code (Current Procedural Terminology):** The 5-digit code used to identify the medical service provided. * **Balance Billing:** The practice of a provider billing a patient for the difference between the CMAC and their actual fee. * **Point-of-Service (POS) Option:** An additional cost incurred when TRICARE Prime members see a provider without a referral. * **T-5 Contract:** The current regional contract (effective 2025/2026) involving Humana Military and TriWest Healthcare Alliance.
## Sources * **TRICARE.mil - Check Rates:** https://www.tricare.mil/rates * **Defense Health Agency (DHA) - CMAC Rates:** https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/CMAC-Rates * **TriWest Healthcare Alliance (West Region):** https://www.triwest.com * **Humana Military (East Region):** https://www.humanamilitary.com