Plan Benefits

Find a full breakdown of your plan with US Family Health Plan below. If you have any further questions about your plan, feel free to give us a call at (800) 241-4848.

Outpatient Services	Active Duty Family Members & Retirees with Medicare Part B	Retirees without Medicare Part B
Office Visits	$0	$20 Per Visit
Specialty Visit	$0	$31 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	$62 Per Visit
Physical Therapy, Occupational Therapy, Speech Therapy	$0	$31 Per Visit

Inpatient Services	Active Duty Family Members & Retirees with Medicare Part B	Retirees without Medicare Part B
Semi-Private Room and Board	$0	$156 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	Active Duty Family Members & Retirees with Medicare Part B	Retirees without Medicare Part B
Outpatient Care: Individual	$0	$31 Per Visit
Outpatient Care: Group	$0	$31 Per Visit
Partial Hospitalization Mental Health (Up To 60 Days Per Enrollment Year, Subject To Medical Review)	$0	$31 Per Visit – Individual $31 Per Visit – Group
Inpatient Hospital Psychiatric Care (Subject To Medical Review)	$0	$156 Per Admission

Substance Abuse Treatment	Active Duty Family Members & Retirees with Medicare Part B	Retirees without Medicare Part B
Outpatient – Group Therapy	$0	$31 Per Visit
Inpatient Services (Up To 7 Days For Detoxification Per Year)^{Maximum of one rehabilitation program per benefit yet, three per lifetime. Detoxification and rehabilitation days count toward the limit for mental health benefits.}	$0	$156 Per Admission
Inpatient Rehabilitation (Up To 21 Days Per Year)	$0	$156 Per Admission

Other Services	Active Duty Family Members & Retirees with Medicare Part B	Retirees without Medicare Part B
Ambulance Service (When Medically Necessary)	$0	$41 Per Occurrence
Durable Medical Equipment, Medical Supplies, and Prosthetic/Orthotic Devices	$0	20% Of Purchase Price Or Monthly Rental Rate
Emergency Room Services^{Unless you are admitted to the hospital, in which case only the inpatient co-pay applies.}	$0	$62 Per Visit
Urgent Care Center	$0	$31 Per Visit
Eye Exam/Eyeglass, Annual Preventative (1 Per Enrollment Period)	$0	$0
Radiation/Chemotherapy Office Visits	$0	$31 Per Visit
Skilled Nursing Facility Care (When Medically Necessary)	$0	$31 Per Day
Home Health Care (Part Time Skilled Nursing Care)	$0	$0

Pharmacy	Active Duty Family Members & Retirees with Medicare Part B	Retirees without Medicare Part B
Retail Pharmacy Drugs (Up To 30 Day Supply)^{Prescription drug availability is limited to those covered as a Plan benefit. Over the counter medications are not covered.}	$13 Generic/$33 Brand Formulary/ $60 Brand, Non-Formulary^{effective 1/1/2020}	$13 Generic/$33 Brand Formulary/ $60 Brand, Non-Formulary^{effective 1/1/2020}
Mail Order Pharmacy Drugs (Up To 90 Day Supply)	$10 Generic/$29 Brand Formulary/$60 Brand, Non-Formulary^{effective 1/1/2020}	$10 Generic/$29 Brand Formulary/$60 Brand, Non-Formulary^{effective 1/1/2020}

Catastrophic Cap	Active Duty Family Members & Retirees with Medicare Part B	Retirees without Medicare Part B
Maximum Out-Of-Pocket Expense Per Family	Active Duty family members: $1,000 Per Enrollment Year (Group B: $1,044/year) Retirees: $3,000 Per Enrollment Year (Group B: $3,655/year)	$3,000 Per Enrollment Year

Catastrophic Cap

Active Duty Family Members & Retirees with Medicare Part B

Retirees without Medicare Part B

Maximum Out-Of-Pocket Expense Per Family

Active Duty family members: $1,000 Per Enrollment Year (Group B: $1,044/year)

Retirees: $3,000 Per Enrollment Year (Group B: $3,655/year)

$3,000 Per Enrollment Year

Enrollment Fees^{Enrollment Fees are subject to change annually}	Active Duty Family Members & Retirees with Medicare Part B	Retirees without Medicare Part B
Group A: Monthly or Annual Payment	$0	Retirees: $300 Per Year – Individual $600 per year – Family TRICAREYoung Adult: $376.00 Per Month
Group B: Monthly or Annual Payment	$0	Retirees: $366 Per Year – Individual $732 per year – Family TRICAREYoung Adult: $376.00 Per Month

pricing is subject to change, and further information is available at www.tricare.mil/cos.