2024-25753. TRICARE; Calendar Year (CY) 2025; TRICARE Prime and TRICARE Select Out-of-Pocket Expenses

Calendar Year 2025 TRICARE Prime and TRICARE Select Out-of-Pocket Expenses—Active Duty Family Members (ADFM) Category

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Out of pocket expense	Select Group A CY25	Select Group B CY25	Prime * Group A CY25	Prime * Group B CY25
Annual enrollment fee:
Individual	$0	$0	$0	$0
Family	$0	$0	0	0
Annual deductible:
E1-E4, individual	$50	$64	0	0
E1-E4, family	$100	$128	0	0
E5 & above, individual	$150	$193	0	0
E5 & above, family	$300	$386	0	0
Annual catastrophic cap	$1,000	$1,288	1,000	1,288
( print page 88031)
Preventive visit	$0	$0	0	0
Primary care	$27 (IN); 20% (OON)	$19 (IN); 20% (OON)	0	0
Specialty care	$38 (IN); 20% (OON)	$32 (IN); 20% (OON)	0	0
ER visit	$105 (IN); 20% (OON)	$51 (IN); 20% (OON)	0	0
Urgent care center visit	$27 (IN); 20% (OON)	$25 (IN); 20% (OON)	0	0
Ambulatory surgery	$25 (IN or OON)	$32 (IN); 20% (OON)	0	0
Ambulance, outpatient ground	$86 (IN); 20% (OON)	$19 (IN); 20% (OON)	0	0
Ambulance, outpatient air	20%; (IN or OON)	20%; (IN or OON)	0	0
Durable medical equipment	15% (IN); 20% (OON)	10% (IN); 20% (OON)	0	0
Inpatient admission	$23.45 per day; $25 min. per admission	$77 per adm. (IN); 20% (OON)	0	0
Inpatient SNF/rehab facility	$23.45 per day; $25 min. per admission	$32 per day (IN); $64 per day (OON)	0	0
* When TRICARE Prime enrollees other than active duty service members self-refer to specialty or non-emergent inpatient care without a referral from a network provider and/or authorization from the regional contractor, the TRICARE Point of Service deductible and copayment applies in lieu of TRICARE Prime copayments.

Calendar Year 2025 TRICARE Prime and TRICARE Select Out-of-Pocket Expenses—Retiree Beneficiary Category

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Out of pocket expense	Select Group A CY25	Select Group B CY25	Prime * Group A CY25	Prime * Group B CY25
Annual enrollment fee:
Individual	$181.92	$579	$372	$450
Family	$364.92	$1,158.96	744	900.96
Annual deductible:
Individual	$150	$193 (IN); $386 (OON)	0	0
Family	$300	$386 (IN); $772 (OON)	0	0
Annual catastrophic cap	$4,261	$4,509	3,000	4,509
Preventive visit	$0	$0	0	0
Primary care	$37 (IN); 25% (OON)	$32 (IN); 25% (OON)	25	25
Specialty care	$51 (IN); 25% (OON)	$51 (IN); 25% (OON)	38	38
ER visit	$140 (IN); 25% (OON)	$103 (IN); 25% (OON)	77	77
Urgent care center visit	$37 (IN); 25% (OON)	$51 (IN); 25% (OON)	38	38
Ambulatory surgery	20% (IN); 25% (OON)	$122 (IN); 25% (OON)	77	77
Ambulance, outpatient ground	$115 (IN); 25% (OON)	$77 (IN); 25% (OON)	51	51
Ambulance, outpatient air	25%; (IN or OON)	25%; (IN or OON)	20	20
Note: The calendar year catastrophic cap for TRICARE Select Group A retirees who are survivors of active duty deceased sponsors or medically retired Uniformed Service members and their dependents is $3,000.

Calendar Year 2025 TRICARE Prime and TRICARE Select Out-of-Pocket Expenses—Retiree Beneficiary Category

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Out of pocket expense	Select Group A CY25	Select Group B CY25	Prime * Group A CY25	Prime * Group B CY25
Durable medical equipment	20% (IN); 25% (OON)	20% (IN); 25% (OON)	20%	20%.
Inpatient admission:
In-network	$250/day up to 25% of hospital charges, plus 20% of sep. billed services	$225 per adm	$193 per adm	$193 per adm.
Out of network	‡ $1,221/day up to 25% of hosp. charges, plus 25% of sep. billed services	25%	$193 per adm	$193 per adm.
Inpatient SNF/rehab facility	$250/day up to 25% of hospital charges, plus 20% of sep. billed services (IN); 25% (OON)	$64 per day (IN); lesser of $386 per day or 20% (OON)	$38 per day	$38 per day.
‡ This is the CY24 rate. The CY25 out of pocket expense will be available mid-December once the DRG payment rates are calculated.
* When TRICARE Prime enrollees other than active duty service members self-refer to specialty or non-emergent inpatient care without a referral from a network provider and/or authorization from the regional contractor, the TRICARE Point of Service deductible and copayment applies in lieu of TRICARE Prime copayments.