Summary of Plan Benefits

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

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.






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