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2020 Cost Information for Ancillary Services

The copayments and cost shares listed below also apply to other radiology services as noted in the TRICARE Reimbursement Manual, Chapter 2, Section 2.2. 

Note: Visit our Copayment and Cost-Share Information page to view 2019 costs. 

  • TRICARE Select, TRICARE Young Adult Select, TRICARE Reserve Select, and TRICARE Retired Reserve annual deductibles apply.  
  • TRICARE Young Adult costs are based on the sponsor's status.
  • Transitional Assistance Management Program (TAMP) beneficiaries (service members and their family members) follow the active duty family member copayment/cost-share information, based on the TRICARE plan type.  

A beneficiary's cost is determined by the sponsor's initial enlistment or appointment date:

  • Group A: Sponsor's enlistment or appointment date occurred prior to Jan. 1, 2018.
  • Group B: Sponsor's enlistment or appointment date occurred on or after Jan. 1, 2018.

Ancillary services may include:

  • Diagnostic radiology and ultrasound services CPT® code range 70000 through 76999
  • Diagnostic imaging studies CPT codes 77001 through 77032; 77051 through 77084
  • Diagnostic nuclear medicine services CPT code range 78012 through 78999
  • Pathology and laboratory services CPT code range 80047 through 89398; 36400 through 36425; 36591 through 36592
  • Cardiovascular studies CPT code range 93000 through 93355
  • Fetal monitoring services CPT code range 59020, 59025 and 59050

TRICARE Prime and TRICARE Prime Remote (not including TRICARE Young Adult)

Active Duty Family Members Retirees and Their Family Members

Group A: $0

Group B: $0

Group A: $0

Group B: $0

TRICARE Select (not including TRICARE Young Adult)

Active Duty Family Members Retirees and Their Family Members

Group A: 

Network Provider: $0
Non-Network Provider: 20%

Group B: 

Network Provider: $0
Non-Network Provider: 20%

Group A: 

Network Provider: $0
Non-Network Provider: 25%

Group B:

Network Provider: $0
Non-Network Provider: 25%

TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR)

TRS TRR
Network Provider: $0
Non-Network Provider: 20%
Network Provider: $0
Non-Network Provider: 25%

 

TRICARE Young Adult (TYA)

TYA Prime TYA Select
Active Duty Family Members Retiree Family Members Active Duty Family Members Retiree Family Members
$0 $0 Network Provider: $0
Non-Network Provider: 20%
Network Provider: $0
Non-Network Provider: 25%

 

 

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