Benefits & Services

The US Family Health Plan covers hospital care, doctor's visits, specialty care, and prescription drugs. For an overview of services and the copayments (if applicable) you will pay for them, see the chart below. In addition to these services, members can receive discounts on eyewear, hearing aids, and more as well as other services to help them stay healthy. For complete details about covered benefits, please view the Member Handbook.

Covered Services Copayment
Active-Duty
Family Member
Co-Payment
Retiree, Survivor &
Family Member
With MediCare Part B*
Co-Payment Retiree,
Survivor & Family Member
Primary Care Provider (PCP) Office Visits No Copayment No Copayment $20 per visit
Specialty Office Visits
when referred by your PCP
No Copayment No Copayment $30 per visit
X-Ray & Lab Tests No Copayment No Copayment No Copayment
Emergency Ambulance Services
Benefit limitations apply
No Copayment No Copayment $40 per occurrence
Home Health Care
No Copayment No Copayment No Copayment
Emergency Room Visits No Copayment No Copayment $60 per visit (waived if admitted)
Maternity Services
Hospital & Professional Services
(prenatal, postnatal), with preauthorization as medically necessary
No Copayment N/A $150 per admission, no separate co-payment for separately billed professional charges
Ambulatory Surgery No Copayment No Copayment $60 per procedure
Prosthetic Devices, Durable
Medical Equipment & Supplies
No Copayment No Copayment 20% of the fee negotiated by Martin's Point
Mental Health
Outpatient Individual / Outpatient Group

No Copayment

No Copayment

$30 per visit
Mental Illness or
Substance Abuse Treatment
Inpatient (must be preauthorized and is subject to annual limitations)
No Copayment No Copayment $150 per admission, no separate co-payment for separately billed professional charges

Effective 2/1/2018

Retail: up to 30-day supply

Prescription Drugs
(formulary generic/formulary brand-name/
non-formulary)

Martin's Point onsite & Mail Order Pharmacies (up to a 90-day supply)*

 

$11 / $28 / $53

 

 

 

 

$7 / $24 / $53

 

$11 / $28 / $53

 

 

 

 

$7 / $24 / $53

 

$11 / $28/ $53

 

 

 

 

$7 / $24 / $53

In-Patient (hospitalization)
Semi-private room, general nursing and hospital services, meals, drugs, labs, operating room & anesthesia services, x-rays, blood, etc., with preauthorization as medically necessary.
No Copayment No Copayment $150 per admission
Skilled Nursing Facility Care
Semi-private room, nursing services, meals/special diets, rehabilitative therapies, drugs, supplies, and appliances furnished by the facility, with preauthorization as medically necessary 
No Copayment
 
No Copayment
 
$30 per day 
POINT OF SERVICE BENEFIT       
Point of Service 
Non-emergency or non-urgent care received out of network without preauthorization
Deductible
Individual: $300 per year
Family: $600 per year
Coinsurance
50% of TRICARE allowable
charge (after deductible)
Deductible
Individual: $300 per year
Family: $600 per year
Coinsurance
50% of TRICARE allowable
charge (after deductible)
Deductible
Individual: $300 per year
Family: $600 per year
Coinsurance
50% of TRICARE allowable
charge (after deductible)

*Some restrictions may apply

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