What happens when beneficiaries receive care outside of the network?

When beneficiaries receive care outside of the network, they must pay up to an allowed amount because services rendered outside the network typically have different cost-sharing responsibilities compared to in-network services. This means that while TRICARE may cover some of the costs for the care received outside the network, beneficiaries are often required to first pay a set deductible, coinsurance, or copayment based on the allowable amount for the service.

The allowed amount refers to the maximum amount that TRICARE will consider for payment; any amount billed by the provider that exceeds this limit may become the responsibility of the beneficiary. This structure encourages the use of network providers, who have agreed to accept lower rates, thus providing more cost-effective care for both TRICARE and the beneficiaries.