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“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).
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“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.
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“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.
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“Accordingly, TRICARE payments
for this equipment will end with whichever of the following occurs first:
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1.
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When $_______ has been reimbursed,
subject to usual deductible and cost-share amounts.
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2.
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When you no longer require
the equipment medically.
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3.
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When your TRICARE eligibility
ends.”
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