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US Family Health Plan > Benefits > USFHP Plan Benefits	Print This Page

Summary of Benefits

Summary of Benefits
	Cost for Active Duty Family Members	Cost for Retirees, Family Members and Survivors	Cost for Retirees and Family Members Enrolled in Medicare Part B
Enrollment Fee	$0	$230 individual $460 family	$0 (with proof of Part B enrollment)
Outpatient Services
Office visits	$0	$12	$0
Maternity care (prenatal, postnatal)	$0	$0	$0
Well-child care (birth to age 6)	$0	$0	$0
Routine physical examinations	$0	$0	$0
X-ray and lab tests¹	$0	$0	$0
Ambulatory surgery (same day)	$0	$25	$0
Physical therapy (when medically necessary)	$0	$12	$0
Inpatient Services
Hospitalization (semi-private room and board)	$0	$11 per day/$25 minimum charge for admission	$0
Maternity care (prenatal, delivery, postnatal hospital and professional services)	$0	$11 per day/$25 minimum charge for admission	$0
Physician services	$0	$0	$0
General nursing services	$0	$0	$0
Diagnostic tests including lab and X-ray	$0	$0	$0
Operating room, anesthesia and supplies	$0	$0	$0
Medically necessary supplies and services	$0	$0	$0
Physical therapy (when medically necessary)	$0	$0	$0
Mental Health Services
Outpatient care individual (subject to medical review)²	$0	$25 per visit	$0
Outpatient care group (subject to medical review)²	$0	$17 per visit	$0
Partial hospitalization mental health (up to 60 days per fiscal year)	$0	$40 per day	$0
Inpatient hospital psychiatric care (subject to medical review)³	$0	$40 per day	$0
Substance Abuse Treatment
Outpatient care (individual)⁴	$0	$25 per visit	$0
Outpatient group/family therapy	$0	$17 per visit	$0
Inpatient services (up to 7 days for detoxification per year)⁵	$0	$40 per day	$0
Inpatient rehabilitation (up to 21 days per year)⁵	$0	$40 per day	$0
Other Services
Ambulance services (when medically necessary)	$0	$20 per occurrence	$0
Dental Care - basic preventive	Reduced fees	Reduced fees	Reduced fees
Durable medical equipment	$0	20%	$0
Emergency room services⁶ (including out of the area)	$0	$30	$0
Comprehensive eye examiniation (1 per year)	$0	$0	$0
Family planning services	$0	$12	$0
Radiation/chemotherapy office visits	$0	$12	$0
Prescription drugs (retail and mail order)⁷	$3 generic $9 brand name $22 Non-pref brand name	$3 generic $9 brand name $22 Non-pref brand name	$3 generic $9 brand name $22 Non-pref brand name
Skilled nursing facility care	$0	$11 per day/$25 minimum charge per admission	$0
Home health care (part-time skilled nursing care)	$0	$12 per visit	$0
Out of area (emergency services only)	$0	$30	$0
Catastrophic cap	$1,000 per enrollment yr.	$3,000 per enrollment yr.	$3,000 per enrollment yr.
Enrollment fee	$0	$230 individual⁸ $460 family⁸	$0 (with proof of Part B enrollment)

Footnotes to chart:

If lab services are provided on the same day as the office visit and a co-pay is collected for the visit, no additional co-pay will be collected. No co-pay will be collected when services are billed and provided as clinical preventive services. Exceptions: co-pay may be required for certain radiation oncology, vascular and pulmonary procedures and studies. Contact Customer Service for details.
One hour of therapy, no more than two times per week, when medically necessary. Includes in-home services.
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 of residential treatment for children and adolescents.
Exclusive of drug maintenance programs.
Maximum of one rehabilitation program per year and three per lifetime. Detoxification and rehabilitation days count toward limit for mental health benefits.
Unless you are admitted to the hospital, in which case only the inpatient co-payment applies.
Prescription drug availability is limited to drugs prescribed by a Plan provider and covered as a Plan benefit. Availability of non-emergency prescriptions when out of the area is also limited. Over-the-counter medications and supplies are not covered. Retail vendor for prescriptions is Rite Aid Pharmacy.
Medicare-eligible enrollees showing evidence of current Part B payment do not have to pay the enrollment fee.

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