US Family Health Plan

Effective for beneficiaries whose sponsor joined the uniformed services before January 1, 2019

Active Duty Family Members Retirees & Retiree Family Members
Annual Enrollment Fee $0 $297 individual, $594 family
Annual Deductible $0 $0
Catastrophic Cap Per Year $1,000 $3,500
Point of Service Option Deductible $300 individual
$600 family
$300 individual
$600 family
Doctors Visits Active Duty Family Members  Retirees & Retiree Family Members 
Preventive Care Visit $0 $0
Primary Care Visit $0 $20
Specialty Care Visit $0 $30
Emergency Room Visit $0 $61
Urgent Care Center $0 $30
Ambulatory Surgery $0 $61
Ambulance Service (not including air) $0 $41
Durable Medical Equipment $0 20%
Inpatient Admission $0 $154 per admission
Inpatient Skilled Nursing / Rehab Admission $0 $30 per day
Prescription Drug Retail Active Duty Family Members Retirees & Retiree Family Members
Prescription Benefits (Maxor Pharamacy)
Prescription Drugs Retail Generic(Tier 1)
$11 Mail Order $7
Retail $11
Brand Name (Tier 2) $28

Mail Order $24
Retail: $28

Non-Formulary (Tier 3) $53 Mail Order: $53
Retail: $53
 Enhancements / Extras / Value Added Discounts  Active Duty Family Members Retirees & Retiree Family Members
 Vision Care  FREE annual eye exam
 Vision Discount  Discounts on glasses and lenses at select providers
 Dental Care Discount  Free initial dental exam and discounts on services at select providers
 Hearing Care  Free annual hearing exam plus 20% off hearing aids at select providers
Transportation Transportation to covered medical services (up to 8 round trips or 16 one-way trips)

*Negotiated fees: The fees network providers and participating non-network providers have agreed to accept for covered services.