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,
Durable Medical Equipment (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 (HHC)
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.
|
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.
|
$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)
|
$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).
|
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 TRICARE Prime enrollees.
|
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.
|