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TRICARE Reimbursement Manual 6010.64-M, April 2021
Chapter 1
Addendum B
Figure 1.B-1  Suggested Wording To The Beneficiary Concerning Rental vs. Purchase Of Durable Medical Equipment (DME)
“We have determined under the Regulation that the total TRICARE benefit allowable, subject to usual deductible and cost-sharing requirements, is $________. This amount is equal to (the allowable purchase price of the equipment) (____ months of estimated medically necessary rental, at $______ allowable rental per month).
“You may obtain this equipment under any arrangement you wish. However, it would be advantageous for you to obtain the equipment by (rental) (purchase or lease/purchase). Any expenses you incur in excess of the TRICARE-allowable amount will be your own responsibility.
“If you are not satisfied with the action taken on your case, you have the right to a review. Your written request for a review must state the specific matter with which you do not agree and must be received in this office within 90 calendar days of this notice.
“Accordingly, TRICARE payments for this equipment will end with whichever of the following occurs first:
When $_______ has been reimbursed, subject to usual deductible and cost-share amounts.
When you no longer require the equipment medically.
When your TRICARE eligibility ends.”
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