TRICARE Glossary: Terms to Know for Your Health Care

TRICARE Glossary: Terms to Know for Your Health Care
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tricare-guide-2023-24-red-shield.pngEditor’s Note: This article by MOAA staff is part of MOAA’s 2023-24 TRICARE Guide, brought to you by MOAA Insurance Plans, administered by Association Member Benefits Advisors (AMBA). A version of the guide appeared in the November 2023 issue of Military Officer magazine. 


Whether you are new to TRICARE or a seasoned beneficiary, odds are you may run into an unfamiliar word or phrase as part of your interactions with your service-earned health benefit.


The glossary below includes TRICARE terminology that may prove helpful in this process. You can find additional resources on the TRICARE website


Allowed amount: Also referred to as “allowable charge,” this is the maximum amount TRICARE will pay a doctor or other provider for a procedure, service, or equipment. Nonparticipating providers can charge you up to 15% more than the allowable charge that TRICARE will pay. If you use a nonparticipating provider, you will have to pay all of that additional charge up to 15%.


Annual deductible: This is the amount you must pay before cost sharing begins. Once you meet your individual or family deductible, TRICARE cost sharing will start.


Catastrophic cap: This is the most you pay out of pocket annually for services covered by TRICARE. All TRICARE plans have a cap. Expenses that apply toward the cap include fees for covered services, including yearly enrollment fees; deductibles; copays; pharmacy copays; and other cost shares based on TRICARE-allowable charges. What doesn’t apply are monthly premiums for premium-based plans and point-of-service fees for TRICARE Prime.


Copay: This is the fixed dollar amount you pay for a covered health care service or drug. For appointments, the copay also covers your costs for tests and other ancillary services as part of the appointment. Copays for non-network providers are 25% of the allowable charge.


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Cost share: This is the percentage you will pay of the total cost of a covered health care service, and it applies to all TRICARE plans. You might be paying separate cost shares for one event; for example, for a surgery you might have separate cost shares for the surgeon, the facility, and the anesthesiologist.


Explanation of Benefits (EOB): The EOB is an itemized statement showing what actions TRICARE has taken on your claims. It is not a bill for services. It’s a good idea to file EOB statements with your health insurance records for reference. After reviewing your EOB, you can appeal if you disagree with a decision made about your benefit. You can file an appeal within 90 days of the date of the EOB notice.


Formulary: The TRICARE formulary is a list of generic and brand-name prescription drugs that TRICARE covers for its beneficiaries. The formulary is reviewed and updated each quarter, and some drugs may be moved from one category to another. You should receive a letter from Express Scripts to notify you when a formulary drug you take becomes listed as nonformulary. Higher out-of-pocket costs generally come with nonformulary drugs.


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Network providers: These are TRICARE-authorized providers who have signed a contract with your regional contractor. Network providers accept a negotiated rate as payment in full, and they will file claims. You’ll see them if you are in TRICARE Prime and might see them in TRICARE Select, but you are not required to do so.


Non-network providers: They are authorized to provide care to TRICARE beneficiaries but have not signed an agreement with TRICARE and have no formal agreement with your TRICARE contractor. They have an option to file claims with TRICARE for you. They might require payment from you upfront.


Open season: This is an annual period when you can enroll in or change your health care coverage for the next year. Enrollment changes made during open season will go into effect Jan. 1, 2024. Open season this year begins Nov. 13 and ends Dec. 12.


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Point-of-service fees: If you have TRICARE Prime, this is what you pay when seeing a TRICARE-authorized provider other than your primary care manager for nonemergency services without a referral. You pay an annual deductible of $300 per individual/$600 per family before TRICARE cost sharing begins. For health care services beyond the deductible, you pay 50% of the TRICARE-allowable charge. These costs will not apply toward your catastrophic cap.


Premium: This is the amount you pay for your health insurance every month. In addition to your premium, you usually have to pay other costs, including a deductible and copays.


Qualifying Life Event (QLE): A QLE is a change in your life such as marriage, birth of a child, or retirement from active duty, which might mean different TRICARE health plans are available to you and your family members. A TRICARE QLE opens a 90-day period for you to make eligible enrollment changes. A QLE for one family member creates an opportunity for all eligible family members to make enrollment changes.


TRICARE For Life (TFL): TFL supplements Medicare coverage for TRICARE-eligible beneficiaries who have Medicare Parts A and B or a Medicare Advantage Plan (Part C).


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TRICARE Prime: An assigned primary care manager provides most of your care in TRICARE Prime service areas. Active duty servicemembers pay nothing out of pocket unless the family uses the point-of-service option; all other beneficiaries pay enrollment fees and network copays.


TRICARE Select: This is a self-managed, preferred provider organization plan. TRICARE contracts with a network of doctors, hospitals, and other providers. You have more freedom of choice but more out-of-pocket costs than in Prime.



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