| 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: individual 1 |
$0 |
$25 per visit |
| Outpatient care: group 1 |
$0 |
$17 per visit |
| Partial hospitalization mental health (up to 60 days per enrollment 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 year) 3 |
$0 |
$40 per day |
| Inpatient rehabilitation (up to 21 days per year) 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 services 4 |
$0 |
$30 per visit |
| Eye exam, annual preventative (1 per enrollment period) |
$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 |
$12 per visit |
| PHARMACY (Over the counter medications are not covered) |
| Prescription drugs 5 (up to 30 day supply) |
$3 generic/$9 brand/$22 3rd tier |
$3 generic/$9 brand/$22 3rd tier |
| Mail order pharmacy drugs 5 (up to 90 day supply) |
$3 generic/$9 brand/$22 3rd tier |
$3 generic/$9 brand/$22 3rd tier |
| CATASTROPHIC CAP |
| Maximum out-of-pocket expense per family |
$1,000 per enrollment year - Active Duty family members
$3,000 per enrollment year - Retirees |
$3,000 per enrollment year |
| YEARLY ENROLLMENT FEE |
$0 |
$230 per individual
$460 per family |
| 1 |
One hour of therapy, no more than two times per week, when medically necessary. |
| 2 |
With authorization, up to 30 days per enrollment year for adults (age 19+); up to 45 days per enrollment year for children under age 19; up to 150 days residential treatment for children and adolescents. |
| 3 |
Maximum of one rehabilitation program per 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, eyeglasses, contact lenses, 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. |
