Understanding TRICARE deductibles: What you need to know

Have you ever heard the word "deductible" and wondered what it means? You aren’t alone. Healthcare cost terms can be tricky, but we’re here to make them easy to understand.

"A deductible is a set amount of money you must pay out of pocket before TRICARE starts to pay for your care," said Debra Fisher, TRICARE health system specialist, TRICARE Health Plan, at the Defense Health Agency. "Knowing your deductible is the first step in planning your family's healthcare budget."

How a deductible works Imagine your deductible is like an empty bucket. Every time you see a provider, you put money into the bucket. Once the bucket is full, your deductible is met.

After your bucket is full, TRICARE steps in to help pay your medical bills. You’ll usually just pay a smaller amount, called a copayment or cost-share, for the rest of the year.

TRICARE uses a calendar year for tracking your deductible. That means your bucket empties out every Jan. 1, and you start filling it again.

Which TRICARE plans have a deductible? TRICARE has many different plans. Some have a deductible, and some don’t:

• TRICARE Select: If you use TRICARE Select, you have a yearly deductible, as described in the TRICARE Costs and Fees Sheet. You must pay this set amount every calendar year before TRICARE benefits are payable.
• Premium-based plans: Premium-based plans, like TRICARE Reserve Select, TRICARE Retired Reserve, TRICARE Young Adult, and the Continued Health Care Benefit Program, also have deductibles.
• TRICARE Prime: If you’re enrolled in TRICARE Prime, you usually don’t have a deductible. But be careful: If you have TRICARE Prime and see a provider outside your network without a referral, you’ll use the point-of-service option. If you do this, you have a separate POS deductible, which is higher than standard cost-sharing.

What counts towards your deductible? Now, what money actually goes into your deductible bucket?

• Doctor visits and hospital care: When you pay for covered visits, those costs count. But remember, they only count up to the TRICARE-allowable charge. If a provider charges $200, but the TRICARE-allowable charge is only $100, only the $100 goes into your bucket.

What does NOT count? There are a few things that don’t go into your bucket:

• Monthly premiums: If you pay a monthly premium, that money doesn’t go into your deductible bucket.
• Non-covered services: If you buy something TRICARE doesn’t cover, like a special non-medical comfort item, that extra money doesn’t count toward your deductible.
• Pharmacy costs: The money you pay for your covered drugs at the pharmacy doesn’t go toward your deductible.

The special rules for TRICARE Select If you’re a Group B retiree with TRICARE Select, you need to pay close attention. You actually have two separate buckets. You have one deductible for providers in the TRICARE network, and a separate deductible for non-network providers. If you fill your network bucket, it doesn’t fill your non-network bucket. You must pay the non-network deductible in addition to the in-network one if you choose to see non-network providers.

How to check your bucket Do you want to know how close you are to filling your deductible bucket? Just look at your explanation of benefits after a medical visit. Your EOB will have a line that shows exactly how much money was applied to your deductible.

Once you meet your deductible and pay your copayments and cost-shares, you also build up to your catastrophic cap. This is a limit on how much you pay out of pocket for your covered care in one year. Once you hit this cap, TRICARE pays 100% of your covered care.

The bottom line Understanding your deductible is the first step in managing your family’s healthcare budget. By knowing whether you have a bucket to fill and tracking your progress through your EOBs, you can avoid surprises at your next medical visit.

Remember, once your deductible is met, TRICARE steps in to pay a large share of your healthcare costs—and the catastrophic cap is there to limit your out-of-pocket expenses.

If you have questions about your specific plan’s deductible and copayments or cost-shares, visit the TRICARE Plan Finder or log in to your regional contractor’s portal to see your current balance.