TRICARE Coinsurance: Definition and 2026 Costs | TRICARE.com

## Definition Coinsurance is the percentage of the total cost of a covered healthcare service that you pay out-of-pocket after you have met your annual deductible.

## What it means in practice While a "copayment" is a fixed dollar amount (like $30 for a doctor visit), **coinsurance** is a slice of the pie. In the TRICARE system, coinsurance typically applies when you use TRICARE Select, or when TRICARE Prime members seek care without a referral (Point-of-Service option). The specific percentage you pay depends on your sponsor's military status (Active Duty vs. Retiree) and your "Group" status based on when the sponsor joined the military.

For example, under **TRICARE Select** in 2026, a Group A retiree might be responsible for 25% coinsurance for an out-of-network outpatient visit. If the TRICARE-allowable charge for that visit is $200, the beneficiary would pay $50 (25%) and TRICARE would pay $150 (75%), provided the annual deductible has already been met. If the deductible has not been met, the beneficiary pays the full $200 until the deductible requirement is satisfied.

For those using **TRICARE Prime**, coinsurance is less common but appears prominently under the **Point-of-Service (POS) option**. If a Prime enrollee sees a specialist without a referral from their Primary Care Manager, they are subject to a 50% coinsurance rate for the TRICARE-allowable charge after the POS deductible is met. This can result in significantly higher out-of-pocket costs compared to standard network copays.

It is important to note that coinsurance is calculated based on the "TRICARE-allowable charge," not necessarily what the doctor bills. If you see a non-participating non-network provider, you may be responsible for the coinsurance plus "balance billing," which can be up to an additional 15% of the allowable charge. All coinsurance payments count toward your annual **Catastrophic Cap**, which limits your total out-of-pocket liability for the year.

## Related terms * **Deductible:** The fixed amount you must pay out-of-pocket each calendar year before TRICARE begins to share the costs of covered services. * **Copayment:** A fixed dollar amount (e.g., $15 or $30) that you pay for a specific medical service or prescription. * **Catastrophic Cap:** The maximum dollar amount you or your family will pay for covered TRICARE services in a single calendar year. * **Allowable Charge:** The maximum amount TRICARE will pay for a covered medical service, regardless of what the provider actually bills. * **Point-of-Service (POS) Option:** An option for TRICARE Prime enrollees to see any TRICARE-authorized provider without a referral, resulting in higher coinsurance and deductibles.

## Sources * TRICARE.mil: Cost Terms [https://www.tricare.mil/Costs/Cost-Terms](https://www.tricare.mil/Costs/Cost-Terms) * TRICARE.mil: TRICARE Select Costs [https://www.tricare.mil/Costs/HealthPlanCosts/TS](https://www.tricare.mil/Costs/HealthPlanCosts/TS) * Defense Health Agency: Annual Cost Updates [https://health.mil/Military-Health-Topics/Access-Cost-Quality/TRICARE/TRICARE-Costs](https://health.mil/Military-Health-Topics/Access-Cost-Quality/TRICARE/TRICARE-Costs)

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