TRICARE Provider Reimbursement Rates & Rules 2026 | TRICARE.com

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## Quick answer TRICARE reimburses healthcare providers based on a set fee schedule, generally tied to Medicare rates, rather than what a doctor chooses to bill. For out-of-network care, providers can charge up to 15% above the TRICARE allowable amount, though the patient is often responsible for this "excess charge."

Details

### The TRICARE Allowable Charge (TAC) At the heart of TRICARE reimbursement is the **TRICARE Allowable Charge (TAC)**. This is the maximum amount TRICARE will pay for a specific medical service or supply. TRICARE uses several "reimbursement methodologies" to determine these rates:

* **CMAC (CHAMPUS Maximum Allowable Charge):** This is the most common method. It is based on Medicare’s Resource-Based Relative Value Scale (RBRVS) but adjusted for the military health system. * **DRG (Diagnosis Related Group):** Used for most inpatient hospital stays. * **OPPS (Outpatient Prospective Payment System):** Used for hospital outpatient services.

### Reimbursement by Provider Status How much a provider is reimbursed—and how much the patient pays—depends on the provider’s relationship with the regional contractors (Humana Military in the East or TriWest Healthcare Alliance in the West).

1. **Network Providers:** These doctors have signed a contract with Humana or TriWest. They agree to accept the TRICARE Allowable Charge as full payment (minus the patient's cost-share). They cannot "balance bill" the patient for the difference. 2. **Participating Non-Network Providers:** These doctors do not have a contract but agree to file claims for TRICARE and accept the TAC on a case-by-case basis. 3. **Non-Participating Non-Network Providers:** These doctors do not agree to the TAC. They can charge up to **15% above the allowable charge**. This is known as the "balance billing" limit. For example, if the TAC for a 2026 visit is $100 but the doctor charges $115, the patient must pay the $15 difference in addition to their standard copay.

### 2026 Participation Trends Under the T-5 contract (which began in 2025), TRICARE has increased its focus on "value-based" reimbursement models. This means some providers may receive incentive payments based on health outcomes rather than just the volume of visits.

### Pharmacy and Specialty Reimbursement * **Pharmacy:** Managed by **Express Scripts**. Reimbursement for retail pharmacies is based on contracted rates that differ from medical billing. * **Mental Health:** TRICARE uses specific rates for residential treatment centers (RTCs) and psychiatric partial hospitalization programs (PHPs).

## Who this affects * **Active Duty Service Members:** Always covered at 100% when using authorized providers; reimbursement rates rarely impact their out-of-pocket costs. * **Active Duty Family Members:** Impacted if they see non-network providers (especially under TRICARE Select). * **Retirees and their Families:** Frequently impacted by balance billing if using non-participating providers under TRICARE Select or TRICARE For Life. * **National Guard and Reserve:** Those on TRICARE Reserve Select must ensure providers are "participating" to avoid excess charges.

## Sources * **TRICARE.mil:** [Cost Terms and Definitions](https://www.tricare.mil/Costs/Cost-Terms) * **Defense Health Agency (DHA):** [Rate and Reimbursement Descriptions](https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement) * **TriWest Healthcare Alliance:** [Provider Reimbursement Information](https://www.triwest.com/en/provider/) * **Humana Military:** [Claims and Reimbursement Guide](https://www.humanamilitary.com/provider/)