Summary of Costs & 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 | $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 |
| Cardiac Rehabilitation9 | $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 | $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 | $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 | $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.
- Outpatient treatment following the initial intake evaluation and testing is limited to a maximum of 36 sessions per cardiac event.
