COVERED SERVICES

COST TO MEMBER

Active Duty Family Members & Retirees with Medicare Part B Retirees without Medicare Part B
OUTPATIENT SERVICES
Office visits $0 $12 per visit
Maternity care (prenatal, postnatal) $0 $0
Well-baby care (up to age 6) $0 $0
Annual well-child care (age 6 and older) $0 $0
Annual Physical Examination $0 $0
X-ray and lab tests $0 $0
Ambulatory surgery and procedures, including anesthesia $0 $25
Physical therapy, occupational therapy, speech therapy $0 $12 per visit
INPATIENT SERVICES
Semi-private room and board $0 $11 per day/$25 minimum charge per admission
Physician services $0 $0
General nursing services $0 $0
Diagnostic tests, including lab and X-ray $0 $0
Operating room, anesthesia, and supplies $0 $0
Medically necessary supplies and services $0 $0
Physical therapy $0 $0
BEHAVIORAL HEALTH SERVICES
Outpatient care: individual1 $0 $25 per visit
Outpatient care: group1 $0 $17 per visit
Partial hospitalization mental health (up to 60 days per fiscal year) $0 $25 per visit – individual $17 per visit – group
Inpatient hospital psychiatric care (subject to medical review)2 $0 $40 per day
SUBSTANCE ABUSE TREATMENT
Outpatient – group therapy $0 $17 per visit
Inpatient services (up to 7 days for detoxification per episode)3 $0 $40 per day
Inpatient rehabilitation (up to 21 days per benefit period)3 $0 $40 per day
OTHER SERVICES
Ambulance service (when medically necessary) $0 $20 per occurrence
Durable medical equipment and medical supplies $0 20%
Emergency room services4 $0 $30 per visit
Eye exam, annual preventative (Routine eye examination once every two years for all TRICARE Prime enrollees age three and older) $0 $0
Radiation/chemotherapy office visits $0 $0
Skilled nursing facility care (when medically necessary) $0 $11 per day/$25 minimum per admission
Home health care (part time skilled nursing care) $0 $0
PHARMACY (Over the counter medications are not covered)
Retail network pharmacy drugs (up to 30 day supply)5 $10 generic/$24 brand, formulary/$50 brand, non-formulary $8 generic/$20 brand, formulary/$47 brand, non-formulary
Mail order pharmacy drugs (up to 90 day supply)5 $0 generic/$20 brand, formulary/$49 brand, non-formulary $0 generic/$16 brand, formulary/$46 brand, non-formulary
CATASTROPHIC CAP
Maximum out-of-pocket expense per family $1,000 per fiscal year (per year) – Active Duty family members $3,000 per year – Retirees $3,000 per year
ENROLLMENT FEES
Monthly or Annual payment $0 Family: $565.20 per year
Individual: $282.60 per year
TRICARE YOUNG ADULT: $306 per month
ENROLLMENT FEES AS OF 10/1/2015

PLEASE NOTE: ENROLLMENT FEES ARE SUBJECT TO CHANGE ANNUALLY

1. One hour of therapy, no more than two times per week, when medically necessary.

2. With authorization, up to 30 days per year for adults (age 19+); up to 45 days per year for children under age 19; up to 150 days per year residential treatment for children and adolescents.

3. Maximum of one rehabilitation program per benefit year, three per lifetime. Detoxification and rehabilitation days count toward the limit for mental health benefits.

4. Unless you are admitted to the hospital, in which case only the inpatient co-pay applies.

5. Prescription drug availability is limited to those covered as a Plan benefit. Over the counter medications are not covered.

EXCLUSIONS: Some of the items and services not covered are: chiropractic care, cosmetic surgery, hearing aids, dental care, investigational/experimental treatments, unauthorized care (except for medical emergencies) and services, such as Worker’s Compensation, for which another party is legally responsible. NOTE: This chart highlights US Family Health Plan’s benefits and exclusions.