How Much Does TRICARE Pay for Cataract Surgery?

TRICARE, a healthcare program for uniformed service members, retirees, and their families, helps manage medical expenses. Cataract surgery is a common procedure designed to restore vision by removing a clouded natural lens and replacing it with an artificial one. This article clarifies TRICARE’s coverage for cataract surgery, detailing coverage criteria, potential out-of-pocket expenses across different plans, and services that incur additional costs.

TRICARE Coverage Criteria for Cataract Surgery

TRICARE covers cataract surgery when it is medically necessary due to significant vision impairment. The cataract must substantially affect a beneficiary’s vision and daily activities, requiring a physician’s diagnosis and recommendation.

Coverage includes the standard intraocular lens (IOL), a fixed lens designed for single focal point vision. TRICARE covers facility services, doctor services, and supplies for inserting this standard monofocal IOL. For many TRICARE plans, including TRICARE Prime and the US Family Health Plan, a referral from a primary care manager (PCM) or prior authorization from the regional contractor is often required for specialty care like cataract surgery.

Without proper authorization or documentation of medical necessity, beneficiaries may face higher out-of-pocket costs or denial of coverage. TRICARE’s coverage aims to restore basic functional vision, not to enhance it beyond medical necessity.

Out-of-Pocket Costs by TRICARE Plan

Out-of-pocket costs for cataract surgery under TRICARE vary by plan, beneficiary group, and provider network status. Active-duty service members typically have no out-of-pocket costs for covered services. However, active-duty family members, retirees, and others will have cost-shares, deductibles, and catastrophic caps.

For TRICARE Prime enrollees, in-network out-of-pocket costs are usually minimal. Active-duty family members in Group A (initial enlistment before January 1, 2018) and Group B (initial enlistment on or after January 1, 2018) generally have no annual deductible. Their annual catastrophic cap is $1,000 for Group A and $1,288 for Group B in 2025. Once this cap is met, TRICARE pays the full allowable amount for remaining covered services.

TRICARE Select involves deductibles and cost-shares. For active-duty family members, the 2025 individual deductible for Group B (E-4 and below) is $64, and for Group B (E-5 and above) is $193. Family deductibles are $128 and $386 respectively. After meeting the deductible, beneficiaries pay a percentage of the TRICARE-allowable charge, typically 15-20% for in-network services and 20-25% for out-of-network services.

Retirees and their families in TRICARE Select also face varying deductibles and cost-shares. For instance, a Group A retiree family might see their catastrophic cap increase to $4,261 in 2025, while Group B retirees may face a cap of $4,509.

The US Family Health Plan (USFHP) has a cost structure similar to TRICARE Prime, emphasizing care coordination. Beneficiaries typically have minimal or no out-of-pocket costs for covered services when following the plan’s referral and authorization processes. For example, physician services and diagnostic tests often have no copayment, while hospitalizations may incur a per-admission charge, such as $193 for Group B retirees in 2025.

TRICARE For Life (TFL) serves as a secondary payer to Medicare for Medicare-eligible beneficiaries. Medicare pays first for covered services, and TFL typically covers remaining out-of-pocket costs like Medicare deductibles and coinsurance. This arrangement generally results in very low or no out-of-pocket expenses for medically necessary cataract surgery, provided the beneficiary has both Medicare Parts A and B. The catastrophic cap for TFL beneficiaries is $3,000 for retirees and their family members in 2025.

Additional Costs and Non-Covered Services

While TRICARE covers medically necessary cataract surgery with a standard intraocular lens (IOL), beneficiaries should be aware of additional costs for elective upgrades or non-covered services. TRICARE explicitly covers the standard monofocal IOL, which provides vision at a single focal point. If a beneficiary opts for a non-standard or premium IOL, such as a multifocal, toric, or extended depth-of-focus lens, they are responsible for the cost difference. TRICARE does not pay for services related to the presbyopia or astigmatism-correcting features of such lenses.

Laser-assisted cataract surgery is generally not covered by TRICARE if the laser portion is considered an elective or refractive enhancement. TRICARE focuses on the functional removal of the cataract and implantation of a basic lens, not advanced refractive correction. Any additional fees for laser technology beyond traditional surgery are out-of-pocket expenses. TRICARE also does not cover refractive corneal surgery, orthokeratology, or eye exercises.

Seeking care from non-TRICARE authorized providers without proper authorization, or using the point-of-service option without a referral, will result in higher deductibles and copayments. Unexpected complications might also lead to additional costs if they involve services or supplies not covered by TRICARE. Beneficiaries should confirm coverage and potential out-of-pocket expenses with their provider and TRICARE regional contractor before proceeding with any elective enhancements.

Locating a TRICARE Provider

To find an ophthalmologist or surgical center that accepts TRICARE for cataract surgery, utilize program resources. The TRICARE website offers a “Find a Doctor” search tool and provider network directories, allowing users to search by location and specialty. Always confirm a provider’s TRICARE participation status directly with their office before scheduling an appointment.

Regional contractors, such as Humana Military for the East Region and TriWest Healthcare Alliance for the West Region, also maintain online provider directories. These directories help find network providers who have agreements with TRICARE, typically resulting in lower out-of-pocket costs and reduced administrative burden. For TRICARE For Life beneficiaries, searching Medicare’s “Find and Compare Providers” page is also advisable, as TFL works with Medicare. After identifying potential providers, verify your specific TRICARE plan coverage and any referral or authorization requirements with both the provider’s office and your TRICARE regional contractor.