Cost-Shares

You’ll pay cost-shares for covered dental services, as well as your monthly premiums. Your cost-shares depend on:

• Your sponsor’s pay grade
• Where you live (the CONUS50 United States, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands service area or the OCONUSAreas outside of the 50 United States, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands service Area)

Covered Services	CONUS Service Area Pay Grades E-1–E-4	CONUS Service Area Pay Grades E-5 and above	OCONUS Service Area Command-Sponsored Beneficiaries1
	Diagnostic	0%	0%	0%
Preventive2	0%	0%	0%
Sealants (Sealants included at 0% after May 1, 2017)	20%	20%	0%
Consultation/Office Visit	20%	20%	0%
Post-Surgical Services	20%	20%	0%
Basic Restorative	20%	20%	0%
Endodontic	30%	40%	0%
Periodontic	30%	40%	0%
Oral Surgery	30%	40%	0%
General Anesthesia	40%	40%	0%
Intravenous Sedation	50%	50%	0%
Miscellaneous Services (occlusal guard, athletic mouth guard)	50%	50%	0%
Other Restorative	50%	50%	50%
Implant Services	50%	50%	50%
Prosthodontic	50%	50%	50%
Orthodontic3	50%	50%	50%

¹ Doesn’t apply to Selected Reserve and Individual Ready Reserve members (other than Special Mobilization Category) and their families. They’ll pay CONUS cost-shares.

² The TDP fully covers space maintainers for posterior teeth for enrollees under age 19. They’re covered at a 20% cost-shareA percentage of the total cost of a covered health care service that you pay. for enrollees under age 19 when replacing anterior teeth only. The TDP covers sealants at 20%, as noted above.

³ Available for enrolled family members. The TDP covers:

• Children up to age 21 or 23, based on their student status
• Spouses up to age 23
• National Guard and Reserve sponsors up to age 23

Your dental coverage has specific limits and exclusions. See the TRICARE Dental Program Handbook for more information.