INDIVIDUAL
PROVIDER SERVICES
Office visits; urgent care; outpatient
office-based medical and surgical care; consultation, diagnosis
and treatment by a specialist; allergy tests and treatment; osteopathic
manipulation; medical supplies used within the office including
casts, dressings, and splints.
|
$0 copayment per
visit.
|
$0 copayment per
visit.
|
$12 copayment per
visit.
|
ADFMs:
Cost-share--15% of
the fee negotiated by the contractor.
Retirees,
their Family Members, & Survivors:
Cost-share--20% of
the fee negotiated by the contractor.
|
ADFMs:
Cost-share--20% of
the allowable charge.
Retirees,
their Family Members, & Survivors:
Cost-share--25% of
the allowable charge.
|
OUTPATIENT
HOSPITAL DEPARTMENTS
Clinics visits; urgent care; therapy visits;
medical supplies; consultations; treatment room; etc.
Note:
Use other parts of this table for cost-sharing of ASC services,
ER services, DME, etc.
|
$0 copayment per
visit.
|
$0 copayment per
visit.
|
$12 copayment per
visit.
No
separate copayment/cost-share for separately billed professional charges.
|
ADFMs:
Cost-share--15% of
the fee negotiated by the contractor.
Retirees,
their Family Members, & Survivors:
Cost-share--20% of
the fee negotiated by the contractor.
|
ADFMs:
Cost-share--20% of
the allowable charge.
Retirees,
their Family Members, & Survivors:
Cost-share--25% of
the allowable charge.
|
ANCILLARY
SERVICES
Refer to Section 1 for specific services considered
as ancillary services.
|
$0 copayment per
visit.
|
$0 copayment per
visit.
|
No copayment (see
Note 3).
|
OTHER
RADIOLOGY SERVICES
Not considered as ancillary services.
|
$0 copayment per
visit.
|
$0 copayment per
visit.
|
$12 copayment per
visit.
|
ROUTINE
PAP SMEARS
Frequency to
depend on physician recommendations based on the published guidelines
of the American Academy of Obstetrics and Gynecology (see Note 1).
|
No copayment.
|
No copayment.
|
No copayment.
|
$0 cost-share.
|
$0 cost-share.
|
AMBULANCE
SERVICES
When medically
necessary as defined in the TRICARE Policy Manual (TPM) and the service
is a covered benefit.
|
$0 copayment per
visit.
|
$0 copayment per
visit.
|
$20 copayment per
occurrence.
|
ADFMs:
Cost-share--15% of
the fee negotiated by contractor.
Retirees,
their Family Members, & Survivors:
Cost-share--20% of
the fee negotiated by the contractor.
|
ADFMs:
Cost-share--20% of
the allowable charge.
Retirees,
their Family Members, & Survivors:
Cost-share--25% of
the allowable charge.
|
EMERGENCY
SERVICES
Emergency care
obtained on an outpatient basis, both network and non-network, and
in and out of the Region.
|
$0 copayment per
visit.
|
$0 copayment per
visit.
|
$30 copayment per
emergency room visit.
|
DME, HEARING
AIDS FOR ADFMs, AND MEDICAL SUPPLIES PRESCRIBED BY AN AUTHORIZED
PROVIDER WHICH ARE COVERED BENEFITS
(If dispensed for use outside of the office
or after the home visit.)
|
$0 copayment per
visit.
|
$0 copayment per
visit.
|
Cost-share -
20% of the fee negotiated by the contractor.
|
HOME HEALTH
CARE
Part-time or
intermittent skilled nursing and home health aide services, physical, speech,
& occupational therapy, medical social services, routine and
non-routine medical services.
Note: DME,
osteoporosis drugs, pneumoccocal pneumonia, influenza virus and
hepatitis B vaccines, oral cancer drugs, antiemetic drugs, orthotics, prosthetics,
enteral and parenteral nutritional therapy and drugs/biologicals administered
by other than oral methods are services that can be paid in addition
to the prospective payment amount subject to applicable copayment/cost-sharing
and deductible amounts.
|
$0 copayment.
|
$0 copayment.
|
$0 copayment.
|
$0 cost-share.
|
$0 cost-share.
|
HOSPICE
CARE
Note: A
separate cost-share may be (optional) collected by the individual
hospice for outpatient drugs and biologicals and inpatient respite
care.
|
$0 copayment.
|
$0 copayment.
|
$0 copayment.
|
$0
cost-share.
|
$0
cost-share.
|
WELL CHILD
CARE
Up to the age
of six.
|
$0 copayment per
visit.
|
$0 copayment per
visit.
|
$0 copayment per
visit.
|
FAMILY
HEALTH SERVICES
Family
planning. The exclusions listed in the TPM will apply.
|
$0 copayment per
visit.
|
$0 copayment per
visit.
|
$12 copayment per
visit (see Note 1).
|
ADFMs:
Cost-share--15% of
the fee negotiated by contractor.
Retirees,
their Family Members, & Survivors:
Cost-share--20% of
the fee negotiated by the contractor.
|
ADFMs:
Cost-share--20% of
the allowable charge (see Note 10).
Retirees,
their Family Members, & Survivors:
Cost-share--25% of
the allowable charge.
|
OUTPATIENT
MENTAL HEALTH TO INCLUDE HOME CARE, PARTIAL HOSPITALIZATION, INTENSIVE
OUTPATIENT PROGRAMS (IOPs), AND OPIOD TREATMENT PROGRAMS (OTPs)
|
$0 copayment per
visit.
|
$0 copayment per
visit.
|
$12 copayment for
visits (see Note 2).
|
AMBULATORY
SURGERY (same day)
Authorized hospital-based or freestanding
Ambulatory Surgical Center (ASC) that is TRICARE certified.
|
$0
copayment per visit.
|
$0
copayment per visit.
|
$25
copayment.
|
ADFMs:
Cost-share--$25. for
ASC.
Retirees,
their Family Members, & Survivors:
Cost-share--20% of
the fee negotiated by the contractor.
|
ADFMs:
$25.
Retirees,
their Family Members, & Survivors: Lesser of 25% of group
rate or 25% of billed charge.
|
ALL SURGICAL
PROCEDURES REGARDLESS OF WHERE THEY ARE PERFORMED
With the exclusion of those surgical procedures referenced
Section 1, paragraphs 1.2.4.5 and 1.2.4.7.
|
BIRTHING
CENTER
Prenatal care,
outpatient delivery, and postnatal care provided by TRICARE authorized
birthing center.
|
IMMUNIZATIONS
Immunizations required for active duty
family members whose sponsors have permanent change of station orders
to overseas locations.
Note:
Immunizations provided in accordance with TPM, Chapter 7, Sections 2.1, 2.2, and 2.5 are
also covered as a clinical preventive service (see below).
|
$0 copayment per
visit.
|
$0 copayment per
visit.
|
N/A
|
ADFMs:
N/A.
Retirees,
their Family Members, & Survivors:
N/A.
|
ADFMs:
N/A.
Retirees,
their Family Members, & Survivors:
N/A.
|
EYE EXAMINATIONS
(See Note 5)
One routine examination per year for family
members of active duty sponsors.
Note:
Routine eye examinations once every two years provided in accordance with
TPM, Chapter 7, Section 2.2, are covered as a clinical preventive
service (see below) for Prime enrollees.
|
$0 copayment per
visit.
|
$0 copayment per
visit.
|
N/A
|
ADFMs:
N/A.
Retirees,
their Family Members, & Survivors:
N/A.
|
ADFMs:
N/A.
Retirees,
their Family Members, & Survivors:
N/A.
|
CLINICAL
PREVENTIVE SERVICES
Includes those services listed in the TPM, Chapter 7, Sections 2.1, 2.2, and 2.5.
|
$0 copayment.
|
$0 copayment.
|
$0 copayment.
|
ADFMs:
N/A.
Retirees,
their Family Members, & Survivors:
N/A.
|
ADFMs:
N/A.
Retirees,
their Family Members, & Survivors:
N/A.
|