Copayment
Quick Definition
Fixed amount you pay for covered services.
Video Explanation
Full Definition
A copayment (or copay) is a fixed dollar amount you pay for covered healthcare services at the time of service. The amount varies based on your TRICARE plan, the type of service, and your beneficiary category.
Common copayment examples: • TRICARE Prime civilian provider visit: $0-$34 (varies by rank/status) • TRICARE Select civilian provider visit: Greater of $31 or 27% of negotiated fee • Emergency room visit: $104 (TRICARE Prime), varies (TRICARE Select) • Urgent care: $34 (TRICARE Prime), varies (TRICARE Select)
Copays vs. Cost-shares: • Copays: Fixed dollar amounts (e.g., $31 per visit) • Cost-shares: Percentage of allowable charge (e.g., 20% of the bill)
Active duty service members never pay copays for any care. Active duty family members have lower copays than retirees and their families.
All copays count toward your annual catastrophic cap, providing financial protection against high healthcare costs. Military Treatment Facilities typically don't charge copays for most services.
Related Questions
What is the difference between TRICARE Prime and TRICARE Select?
TRICARE Prime is a managed care option with a primary care manager and lower costs. TRICARE Select offers more flexibility to choose providers with higher out-of-pocket expenses.
How much does TRICARE cost?
Costs vary by plan and beneficiary status. Active duty members have no costs. Retirees and their families pay enrollment fees and cost-shares.
What is TRICARE For Life and who qualifies?
TRICARE For Life is Medicare wraparound coverage for TRICARE-eligible beneficiaries age 65+ who have Medicare Parts A and B.
Does TRICARE cover prescriptions?
Yes, TRICARE covers most prescriptions through military pharmacies, network pharmacies, and home delivery.
Does TRICARE cover mental health services?
Yes, TRICARE covers mental health services including therapy, counseling, and psychiatric care with the same cost-shares as medical services.
How does TRICARE cover emergency room visits and urgent care?
TRICARE covers emergency care worldwide without prior authorization. Visit nearest ER for emergencies; urgent care for non-emergencies.
How does the TRICARE catastrophic cap work?
The catastrophic cap is your maximum annual out-of-pocket cost. Once reached, TRICARE pays 100% of covered services for the rest of the fiscal year.
How much do prescriptions cost with TRICARE?
Prescription costs vary by location: military pharmacies are free, network pharmacies charge $13-$60 copays, and home delivery offers lower costs for 90-day supplies.
What are the TRICARE costs for 2026?
TRICARE 2026 costs vary by plan and beneficiary group. Active duty members pay nothing, while retirees pay enrollment fees, copays, and deductibles that are adjusted annually.
Do I need Medicare Part B with TRICARE?
Yes. If you are a TRICARE beneficiary turning 65, you must enroll in Medicare Part B to keep TRICARE For Life coverage. Late enrollment results in permanent premium penalties.
Does TRICARE cover telehealth visits?
Yes, TRICARE covers telehealth and virtual care visits for a wide range of medical and mental health services with the same cost-shares as in-person visits.
What changed with TRICARE mail-order pharmacy?
TRICARE mail-order pharmacy now requires beneficiaries to confirm auto-refill prescriptions before they ship. This prevents unwanted medication deliveries and potential waste.
Can I have TRICARE and employer insurance at the same time?
Yes, you can have both TRICARE and employer-sponsored health insurance. TRICARE coordinates benefits with other health insurance (OHI), which can reduce your out-of-pocket costs.
What is the TRICARE catastrophic cap for 2026?
The TRICARE catastrophic cap is the annual limit on out-of-pocket expenses. For 2026, active duty families pay no more than $1,000, while retiree family caps range from approximately $3,500 to $4,500.
Do I need a referral for mental health care with TRICARE?
TRICARE Prime requires a referral from your PCM for most mental health care. TRICARE Select allows direct access to network mental health providers without a referral.
Does TRICARE cover annual wellness visits?
Yes, TRICARE covers annual wellness exams and preventive care services at no cost for all beneficiaries when received from a network provider.
Does TRICARE cover weight loss programs?
TRICARE covers medically necessary weight loss treatments including bariatric surgery (with strict criteria), nutrition counseling, and obesity screening. Commercial weight loss programs are not covered.
Does TRICARE cover sleep apnea treatment?
Yes, TRICARE covers sleep apnea diagnosis and treatment including sleep studies, CPAP machines, oral appliances, and in some cases surgery.
Does TRICARE cover allergy testing and shots?
Yes, TRICARE covers allergy testing, allergy shots (immunotherapy), and allergy medications when medically necessary. Referrals may be required under TRICARE Prime.
How many physical therapy visits does TRICARE allow?
TRICARE does not impose a strict limit on physical therapy visits. However, continued treatment must be medically necessary, and authorization may be required for extended courses of care.
Does TRICARE cover dermatology and skin conditions?
Yes, TRICARE covers dermatology visits and treatment for medical skin conditions. Cosmetic procedures like elective mole removal and skin treatments for appearance only are not covered.
Does TRICARE cover genetic testing?
TRICARE covers genetic testing when medically necessary, including BRCA testing for cancer risk, prenatal genetic screening, and testing for hereditary conditions when ordered by a provider.
Does TRICARE cover home births?
TRICARE covers home births when attended by a TRICARE-authorized certified nurse-midwife (CNM). The pregnancy must be low-risk, and specific requirements must be met for coverage.
Does TRICARE cover ambulance and air evacuation?
Yes, TRICARE covers ground and air ambulance services when medically necessary. Coverage includes emergency transport, inter-facility transfers, and air evacuation for critical situations.
What substance abuse treatment does TRICARE cover?
TRICARE covers substance abuse treatment including inpatient rehabilitation, outpatient counseling, detoxification, and medication-assisted treatment (MAT) for alcohol and drug use disorders.
Does TRICARE cover therapy?
Yes, TRICARE covers mental health therapy including individual, group, and family counseling with licensed providers. Referrals may be required under TRICARE Prime.
Does TRICARE cover hearing aids?
Yes, TRICARE covers hearing aids and related services when prescribed by an authorized provider for diagnosed hearing loss.
Does TRICARE cover allergy testing?
Yes, TRICARE covers allergy testing and treatment including skin tests, blood tests, and allergy immunotherapy (allergy shots) when ordered by a TRICARE-authorized provider.
Does TRICARE cover physical therapy?
Yes, TRICARE covers physical therapy when it is medically necessary and prescribed by a TRICARE-authorized provider. Some plans require a referral.
Does TRICARE cover sleep studies?
Yes, TRICARE covers sleep studies (polysomnography) and home sleep tests when medically necessary for diagnosing sleep disorders such as sleep apnea.
Does TRICARE cover vasectomy?
Yes, TRICARE covers vasectomy as a covered surgical benefit. Standard copays and cost-shares apply based on plan type and provider network status.
Does TRICARE cover tubal ligation?
Yes, TRICARE covers tubal ligation (female sterilization) as a covered surgical and preventive care benefit with no cost-share for most beneficiaries.
Does TRICARE cover dermatology?
Yes, TRICARE covers medically necessary dermatology services including treatment for skin conditions, biopsies, and skin cancer screening. Cosmetic dermatology is not covered.
Does TRICARE cover podiatry?
Yes, TRICARE covers podiatry services for medically necessary foot and ankle conditions including treatment of diabetic foot care, fractures, and structural deformities.
Does TRICARE cover durable medical equipment?
Yes, TRICARE covers durable medical equipment (DME) such as wheelchairs, CPAP machines, hospital beds, and oxygen equipment when medically necessary and prescribed by a provider.
Does TRICARE cover ambulance services?
Yes, TRICARE covers ambulance services (ground and air) when medically necessary for emergency transport or interfacility transfers that require medical monitoring.
Does TRICARE cover telehealth?
Yes, TRICARE covers telehealth services including virtual visits with providers for medical and mental health care. Costs are the same as in-person visits.
Does TRICARE cover second opinions?
Yes, TRICARE covers second opinions from another qualified provider. Under TRICARE Prime, a referral may be needed; TRICARE Select allows direct access to another provider.
Does TRICARE cover substance abuse treatment programs?
Yes, TRICARE covers substance abuse treatment including inpatient rehabilitation, outpatient counseling, detoxification, medication-assisted treatment, and intensive outpatient programs.
Does TRICARE cover TMJ treatment?
TRICARE covers TMJ (temporomandibular joint) disorder treatment including diagnostic evaluation, physical therapy, and oral appliances. Surgical treatment requires pre-authorization.
Does TRICARE cover tinnitus treatment?
Yes, TRICARE covers tinnitus evaluation and treatment including audiological assessment, hearing aids if hearing loss is present, and tinnitus retraining therapy.
Does TRICARE cover erectile dysfunction treatment?
Yes, TRICARE covers erectile dysfunction (ED) treatment including diagnostic evaluation, medications, and certain devices when the condition has an organic (medical) cause.
Does TRICARE cover birth control?
Yes, TRICARE covers all FDA-approved birth control methods including oral contraceptives, IUDs, implants, injections, and emergency contraception at no cost-share.
Does TRICARE cover annual physicals?
Yes, TRICARE covers annual preventive health exams at no cost-share for all beneficiaries, including age-appropriate screenings and immunizations.
What is TRICARE Prime?
TRICARE Prime is a managed care health plan similar to an HMO that provides comprehensive coverage with a primary care manager, low out-of-pocket costs, and referrals for specialty care.
What is TRICARE For Life?
TRICARE For Life is Medicare-wraparound coverage for TRICARE-eligible beneficiaries age 65 and older who have both Medicare Part A and Part B.
What is the TRICARE catastrophic cap?
The catastrophic cap is the maximum amount a TRICARE beneficiary family will pay out of pocket for covered services in a fiscal year, after which TRICARE pays 100%.
What is an EOB in TRICARE?
An EOB (Explanation of Benefits) is a statement from TRICARE that details the services billed, amounts paid by TRICARE, and any remaining costs the beneficiary owes.
What is the TRICARE formulary?
The TRICARE formulary is the list of prescription medications approved and covered under the TRICARE pharmacy benefit, organized into tiers that determine copay amounts.
What is cost-sharing in TRICARE?
Cost-sharing in TRICARE refers to the portion of healthcare expenses that beneficiaries pay out of pocket, including enrollment fees, deductibles, copays, and cost-shares.
How to file a TRICARE claim?
Network providers file claims for you. For non-network providers, submit a claim form (DD Form 2642) with an itemized bill to your regional contractor within one year of service.
How to get TRICARE prescription refills?
Refill TRICARE prescriptions at military pharmacies, through Express Scripts home delivery, at retail network pharmacies, or online/by phone through Express Scripts.
How to use TRICARE mail order pharmacy?
Set up TRICARE mail order through Express Scripts by registering online, having your provider send prescriptions electronically, and ordering 90-day supplies delivered to your home.
How to check TRICARE claim status?
Check your TRICARE claim status online through your regional contractor's website, through milConnect, or by calling your contractor's customer service line.
How to get mental health care through TRICARE?
Access TRICARE mental health care by contacting your PCM for a referral (Prime), going directly to a network provider (Select), or calling the Military Crisis Line for emergencies.
How to use TRICARE at urgent care?
Visit any TRICARE-authorized urgent care facility for non-emergency conditions. No referral is needed. Standard outpatient copays apply based on your plan.
How to use TRICARE with other insurance?
When you have both TRICARE and other health insurance (OHI), the other insurance typically pays first and TRICARE pays second, reducing or eliminating your out-of-pocket costs.
How to find a TRICARE-approved pharmacy?
Find TRICARE network pharmacies using the Express Scripts pharmacy locator tool online or through the Express Scripts mobile app, or call 1-877-363-1303.
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