Here's How The TRICARE
Standard/Extra Supplement Plan Works
To Pay Covered Expenses After TRICARE Pays
(This product is currently unavailable in
ME, MT, NH, VT and WA)
| CARE REQUIRED | TRICARE STANDARD/EXTRA PAYS | YOUR TRICARE STANDARD/EXTRA SUPPLEMENT PAYS |
| Inpatient care in civilian hospitals for RETIREES and dependant 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) (AFTER you satisfy the fiscal year Plan Deductible) PLUS 100% of Covered Excess Charges up to the Legal Limit. |
| Inpatient care 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 AFTER you satisfy the fiscal year Plan Deductible PLUS 100% of Covered Excess Charges up to the Legal Limit. |
| Inpatient care 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 AFTER you satisfy the fiscal year Plan Deductible PLUS 100% of Covered Excess Charges up to the Legal Limit. |
| Inpatient care in civilian hospitals for ACTIVE DUTY dependents. | All allowable charges except daily subsistence fee or $25, whichever is greater. | Active Duty Plan - $25 or the daily subsistence fee, whichever is greater, PLUS 100% of Covered Excess Charges up to the Legal Limit. |
| Outpatient care for ACTIVE DUTY dependents (office visits, clinics, lab, prescription drugs, etc.) | 80% of the TRICARE Standard allowed amount (85% for TRICARE Extra) after you pay the TRICARE Outpatient Deductible. | Active Duty Plan - Your cost share PLUS 100% of Covered Excess Charges up to the Legal Limit. |
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The High Option II Supplement Plan pays the Inpatient and Outpatient covered medical expenses once the fiscal year Plan Deductible of $250 per person, $500 per family maximum has been satisfied. Expenses incurred to satisfy the fiscal year TRICARE Outpatient Deductible cannot be used to satisfy the High Option II Plan Deductible. Confined or Confinement means being an Inpatient in
a Hospital (or Skilled Nursing Facility) due to Sickness or Injury. |
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