Summary of Benefits
This chart presents an overview of services that are covered when they are provided or authorized by the Plan and your US Family Health Plan primary care provider (PCP). All specialist visits and hospital admissions must be arranged in advance by your PCP (except for unforeseen medical emergencies). Most copayments are due at the point of service.
| Active Duty Family Members | Retirees, Survivors & Family Members Without Medicare Part B | Retirees, Survivors & Family Members With Medicare Part B* |
|
|---|---|---|---|
| Annual Enrollment Fee | $0 | $260/individual $520/family |
$0 (with proof of Part B enrollment) |
| COVERED SERVICES | YOUR COST | YOUR COST | YOUR COST |
| Annual Physical | $0 | $0 | $0 |
| Outpatient Visits | $0 | $12 | $0 |
| Maternity Care (pre-natal, delivery, post-natal) | $0 | $11/day ($25 minimum) |
$0 |
| Routine Pap Smear | $0 | $0 | $0 |
| Diagnostic Radiology & Lab Tests | $0 | $0 | $0 |
| Well Child Care & Immunizations (up to 24 months of age) | $0 | $0 | $0 |
| Home Health Care | $0 | $12/visit | $0 |
| Emergency Room Visits | $0 | $30 | $0 |
| Ambulatory Surgery | $0 | $25 | $0 |
| Inpatient Hospitalization (general) | $0 | $11/day ($25 minimum) |
$0 |
| Skilled Nursing Facility Care | $0 | $11/day ($25 minimum) |
$0 |
| Ambulance Service | $0 | $20 per occurrence | $0 |
| PRESCRIPTION DRUGS | |||
| Retail Pharmacy (30-day supply) | Copayment per prescription | Copayment per prescription | Copayment per prescription |
| Generic Drug | $5 | $5 | $5 |
| Name-Brand Drug | $12 | $12 | $12 |
| Non-Formulary Drug | $25 | $25 | $25 |
| Mail Order Pharmacy (90-day supply) | Copayment per prescription | Copayment per prescription | Copayment per prescription |
| Generic Drug | $0 | $0 | $0 |
| Name-Brand Drug | $9 | $9 | $9 |
| Non-Formulary Drug | $25 | $25 | $25 |
| OTHER SERVICES | |||
| Durable Medical Equipment (prostheses, supplies) | 0% | 20% of cost | 0% |
| Physical Therapy | $0 | $12/visit | $0 |
| Occupational Therapy | $0 | $12/visit | $0 |
| Rehabilitation Therapy (including cardiac) | $0 | $12/visit | $0 |
| Radiation Therapy | $0 | $12/visit | $0 |
| Eye Exams | $0 | $12 | $0 |
| Chiropractic Care** (Spinal manipulation only) |
$0 | $10/visit | $0 |
| MENTAL HEALTH | |||
| Outpatient Mental Health Visits, individual | $0 | $25/visit | $0 |
| Outpatient Mental Health Visits, group | $0 | $17/visit | $0 |
| Inpatient Hospitalization, Mental Health | $0 | $40/day ($25 minimum) |
$0 |
| Partial Hospitalization, Mental Health | $0 | $40/day ($25 minimum) |
$0 |
| Substance Abuse Treatment (inpatient partial) | $0 | $40/day ($25 minimum) |
$0 |
This summary is not an all-inclusive list. Complete details of benefit coverage and exclusions are available by calling our Member Services department at 1-800-818-8589. The benefits and costs are accurate as of October 1, 2011 but are subject to change by the government.
*If an individual is paying into Medicare Part B, there is no US Family Health Plan enrollment fee for that person. No copayments are due for Medicare-covered services.
**Not a DoD Uniform Benefit. Benefit provided as a service of US Family Health Plan.
Catastrophic Cap: Copayment collections will be subject to a catastrophic cap of $1000 per year for active duty families and $3000 per year for retiree families. This means you won’t have to pay more than that for covered medical services received in a single year. The enrollment fee (if applicable) and all out of pocket copayments are included in determining the catastrophic cap, with the exception of out of pocket costs owed under the Point of Service option.
