TRICARE plan types and what each covers for rehab

Active-duty service members are automatically enrolled in TRICARE Prime and pay nothing for covered addiction treatment , no deductible, no co-pay, no annual maximum. This applies to every level of care: medical detox, residential treatment, PHP, IOP, outpatient therapy, and medication-assisted treatment.

The access path for active-duty at JBSA is through the branch substance abuse program , Army ASAP at Fort Sam Houston, Air Force ADAPT at Lackland and Randolph, Navy and Marine Corps SARP. These programs assess your clinical needs and coordinate referrals. For civilian network providers, a referral comes through your PCM (Primary Care Manager) or the branch program. Going directly to a civilian facility without a referral triggers the point-of-service option, which is expensive and rarely necessary.

For active-duty service members, the primary question is not usually cost , it is confidentiality and career impact. See our guide on self-referral vs command notification at JBSA for those details.

Spouses and dependent children enrolled in TRICARE Prime also pay nothing at military treatment facilities. At civilian network providers with a PCM referral, there is a small co-pay per visit , typically $12 to $30 depending on the provider type. Inpatient care at a civilian network facility requires both a PCM referral and prior authorization from TriWest before admission.

The annual out-of-pocket maximum for non-active-duty Prime family members is $1,000 per year. After you reach that cap, TRICARE covers 100 percent for the rest of the benefit year. This cap resets each January 1.

TRICARE Select is a PPO-style plan. You do not need a referral to see a TRICARE-certified provider , you can call a facility directly. But prior authorization is still required before entering inpatient or residential treatment, and you must use TRICARE-certified facilities to receive covered benefits.

Cost-sharing for in-network care is based on the TRICARE allowable charge. For inpatient treatment, you pay the lesser of $535 per day or 25 percent of the allowable charge, after your annual deductible of $150 per individual or $300 per family. The annual catastrophic cap of $3,500 limits total in-network cost-sharing for the year.

For out-of-network care, cost-sharing jumps to 50 percent of the allowable charge, and the facility may bill you for the difference between their actual charge and TRICARE’s allowable rate. This balance billing is not subject to the annual cap. Out-of-network care should be avoided unless there is no in-network alternative for the level of care you need.

TRICARE for Life acts as a secondary payer to Medicare. Medicare pays first; TFL covers most or all of what remains. For substance use treatment, Medicare Part A covers inpatient detox and residential treatment; Part B covers outpatient treatment, PHP, and IOP. TFL then covers the cost-sharing that would otherwise be the beneficiary’s responsibility.

For most TFL beneficiaries using Medicare-participating providers, out-of-pocket costs for covered addiction treatment are minimal or zero. The Medicare Part A inpatient deductible ($1,676 for 2025) is covered by TFL for the first benefit period. Part B outpatient cost-sharing is also covered by TFL after the Part B annual deductible.

TFL does not require a referral or separate prior authorization from TRICARE , Medicare’s coverage determination governs. Use Medicare-participating providers to get the full TFL benefit. A provider who participates in Medicare but is not separately TRICARE-certified still triggers the TFL benefit when Medicare pays first.

TRICARE Reserve Select is a premium-based plan available to Guard and Reserve members who are not on extended active duty. It works similarly to TRICARE Select , you can see any TRICARE-certified provider without a referral, prior authorization is required for inpatient care, and cost-sharing applies. Monthly premiums are paid by the member.

When Guard or Reserve members are activated for more than 30 consecutive days, they become eligible for TRICARE Prime , the same plan as active-duty , with no cost-sharing for covered care. This activation-based eligibility is automatic and applies from the date of activation.

If you are a Guard or Reserve member and are uncertain of your current TRICARE status, call TriWest at 1-888-874-9378 or the TRICARE Reserve Component support line at 1-800-538-9552.