See what’s covered!

These costs are effective 1/1/2018.

Service Cost
Annual Deductible Network Providers: $0
Point-of-Service Option: $300 for individuals, $600 for family
Ambulance Services $40 per occurrence
Ambulatory Surgery (Same Day) $60
Mental Health (Inpatient) See TRICARE Mental Health Costs
Mental Health (Partial Hospitalization) See TRICARE Mental Health Costs
Mental Health (Outpatient) See TRICARE Mental Health Costs
Clinical Preventive Services $0 from a network provider
DME, Prosthetic Devices, Medical Supplies 20% of the negotiated feeThe discounted rate network providers agree to accept for covered services.
Emergency Services $60 per visit
Home Health Care $0.

Note: You may have separate costs for additional services when receiving home health care. For example, DME, drugs, vaccines, orthotics/prosthetics, and nutritional therapy, among others.

Hospice Care $0
Hospitalization (Inpatient Care) Network Hospital: $150 per admission
Immunizations $0 from a network provider
Laboratory and X-ray Ancillary* services: $0
Other Radiology services: $0
Maternity (office visits and hospitalization for delivery planned in a hospital in an inpatient setting) Office Visits: $0
Delivery: $150

Maternity (office visits for delivery planning in a TRICARE-authorized birthing center) Office Visits: $0
Delivery: $60

Maternity (office visits for delivery planned at home or other setting)

Primary Care Provider: $20 per visit

Specialty Care Provider: $30 per visit

Newborn Care $0
Outpatient Visit Primary Care: $20 per visit
Specialty Care: $30 per visit
Skilled Nursing (Inpatient) $30 per day
Urgent Care $30 per visit

Enhancements

The US Family Health Plans offer discounts on some services, such as vision, dental, alternative medicine, and hearing.