Member Handbook - usfhpnw.org

Member Handbook

US Family Health Plan is for retirees and their family members. The Plan is also open to active duty family members. Eligible survivors are also covered by the Plan.

This member handbook was prepared by US Family Health Plan. It describes Plan benefits. You will also learn how to get services through US Family Health Plan.

Read this member handbook carefully! As you review it, please note the following items. Plan members get healthcare from a network of civilian providers. Members may use the Military Treatment Facility only for emergencies that are life threatening. When US Family Health Plan members need to fill prescriptions, they have two choices. They can get them filled through the Maxor Mail-Order pharmacy or the US Family Health Plan network of retail pharmacies. Pharmacies at the Military Treatment Facility are not part of the US Family Health Plan network of pharmacies.

Welcome to US Family Health Plan

NOTICE OF NONDISCRIMINATION AND ACCESSIBILITY RIGHTSPacific Medical Centers, PacMed, and their Affiliates (collectively “PacMed”) comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. PacMed does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PacMed:

(1) Provides free aids and services to people with disabilities to communicate effectively with us, such as: (a) Qualified sign language interpreters; and (b) Written information in other formats (large print, audio, accessible electronic formats, other formats).

(2) Provides free language services to people whose primary language is not Eng-lish, such as: (a) Qualified interpreters; and (b) Information written in other languages.

If you need any of the above services, please contact the appropriate Civil Rights Coordi-nator below. If you need Telecommunications Relay Services, please call 1-800-833-6384 or 7-1-1.

If you believe that PacMed has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with PacMed by contacting the Civil Rights Coordinator for your service location as listed below:

Service Location Civil Rights CoordinatorPacific Medical Centers Civil Rights Coordinator, 101 W. 8th Ave., Spokane, WA 99204;

Tel: 1-844-469-1775; Interpreter Line: 1-888-311-9127; Email: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, one of the above-noted Civil Rights Coordinators is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Com-plaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F, HHH Building Washington, DC 20201, 1–800–368–1019, 800–537–7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html_________________ For purposes of this notice, “Affiliates” is defined as any entity that is wholly owned or controlled by Western HealthConnect, PacMed Clinics, or Providence Health & Services, including but not limited to all subsidiaries, facilities, and locations operated by those entities.

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US Family Health Plan at Pacific Medical Centers complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

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QUICK REFERENCEMedical EmergenciesLife-threatening emergency . . . . . . . . . . . . . . . . . . . . . . . . 911 (or local emergency number)Urgent care:In service area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Call your primary care providerOut of service area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (800) 585-5883

Member Services and EnrollmentUS Family Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (800) 585-58831200 12th Avenue S, Qtrs 8/9Seattle, WA 98144

Website . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . www.usfhpnw.org

Benefits Questions and Provider ClaimsMember Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (800) 585-5883

Pharmacy ServicesMaxor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (866) 408-2459

Behavioral Health and Substance Abuse ServicesBehavioral Health Department at USFHP . . . . . . . . . . . . 1 (800) 585-5883

Defense Enrollment Eligibility Reporting System (DEERS)Defense Manpower Data Center Support OfficeAttn: COA 400 Gigling Road Seaside, CA 93955-6771

Personal Contacts

My name: __________________________________________________________

My clinic: __________________________________________________________

Main phone: _______________________________________________________

My primary care provider: ______________________________________________

Phone: ___________________________________________________________

Address: _________________________________________________________

My emergency contact: ________________________________________________

Phone: ___________________________________________________________

My pharmacy: _______________________________________________________

Phone: ___________________________________________________________

Phone: 1 (800) 538-9552Fax: (831) 655-8317Online: www.tricare.osd.mil/deers

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Working with Your Primary Care ProviderFor routine care, always call your primary care provider (PCP). If your PCP is not avail-able, the clinic’s staff will arrange for you to be seen by another provider.

If it is after hours, you may still call your PCP’s office. The phone system will transfer your call to an answering service or a consulting nurse.

Getting After-Hours ServiceYou must call your US Family Health Plan clinic for authorization before using after-hours urgent care centers. Your clinic’s phone system will direct you to an after-hours phone service.

What to Do in an EmergencyIf a life is in danger, call 911 or the local emergency number. When you get emergency care, it is important that you contact US Family Health Plan within 24 hours. Call your primary care provider (PCP) or Member Services. This notification can be done by you, a family member, a friend, or the emergency care provider.

If you need urgent care for a situation that is not life threatening, call your PCP’s office. All urgent care must be preauthorized in order to be covered by the Plan.

What to Do When out of the Service AreaYou are covered anywhere in the world for emergency care and urgent care. If you need care when traveling, remember to call your PCP as soon as possible. Let them know that you have been ill and get their advice about your next steps.

Please note that routine or chronic care is not covered out of the US Family Health Plan service area.

How to Fill a PrescriptionNew or refill medications:

US Family Health Plan has an extensive retail pharmacy network. To find a pharmacy that’s convenient for you, please visit us online. Go to www.usfhpnw.org. Click on the “Members” section, and then on “Prescriptions.” Or call Member Services at 1 (800) 585-5883.

Mail-order refills:Please call Maxor Mail-Order at 1 (866) 408-2459. Remember to allow 14 days for deliv-ery. You also may have the medication shipped to a designated address if you will be out of the service area.

Prescriptions resulting from urgent/emergent after hours or weekend visits:

When you receive urgent or emergency care after hours and get a new prescription, you may use Bartel Drugs, a Safeway pharmacy or Rite Aid. If you cannot access one of these pharmacies, you may use any drugstore nearest you. You will need to pay up-front for the medications at these other pharmacies. To be reimbursed, you must submit the receipt for the prescription with a brief explanation of what happened. The receipt

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should show the patient’s name, drug name, quantity dispensed, and amount paid. The receipt will sometimes have the wording “Official receipt, retain for insurance.” If you have not obtained this information, we suggest you call the number on the register tape and request the pharmacy release the prescription information to us via fax.

Copayment AmountsTo receive US Family Health Plan (USFHP) benefits, present your ID card when you receive care.

The following table shows copayments (or “copays”) for common services. Use this table to verify copays if you get care outside of the USFHP network.

You can find a more complete list of copays later in this handbook. You may also call Member Services for information. The number is 1 (800) 585-5883.

For more information about your benefits and coverage, please consult the following Member Handbook.

ServicesActive Duty Family Members & Retirees with Medicare Part B

Retirees, Survivors & Family Members Without Medicare

Part B

Group A Group B Group A Group B

Primary Care Visit $0 $20

Specialty Care Visit $0 $30

Urgent Care Center Visit $0 $30

Emergency Room Visit $0 $60

Inpatient Hospital $0 $150 per admission

Skilled Nursing Facility $0 $30 per day

Durable Medical Equipment $0 20%

Outpatient Mental Health or Substance Use Disorder (SUD)

$0 $30 per visit

Inpatient Mental Health or Substance Use Disorder

$0$30 per day Residential Treatment Facility or

$150 per admission mental health

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Quick Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iiiHow the Plan Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Changes Affecting Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Additions to Your Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Change of Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Enrollment in US Family Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Enrollment Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Enrollment Premium Amounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Quarterly Payment of Enrollment Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Split Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Enrollment Portability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Online Enrollment for Beneficiaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

CONTENTS

US Family Health Plan ✪ 1

TRICARE Young Adult . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11TRICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Other Insurance and Insurance Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Coordination of Benefits (COB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Third-Party Liability and Work-Related Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . 12Medicare Eligibles: If You Are 65 or Older . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

The Role of Your Primary Care Provider (PCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Choosing Your Primary Care Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13The Referral Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13The Referral Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14About Referrals to Specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Hospital Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

If You Are Admitted to a Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Point of Service (POS) Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Point of Service Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Point of Service Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Military Treatment Facility Privileges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Utilization Management and Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Medically Necessary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Extended Care Health Option (ECHO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17After-Hours Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17If You Are Traveling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Summary of Benefits Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18–19

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Filling Your Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Services and Locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

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Prescriptions for After Hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Prescriptions When Traveling out of the Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Prescription Drug Limitations and Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Catastrophic Loss Protection Benefit (Catastrophic Cap) . . . . . . . . . . . . . . . . . . . 23Outpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Behavioral Health and Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

What Is Covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Skilled Nursing Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Inpatient Skilled Nursing Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25What Is Covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Medical Eye Exams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25What Is Not Covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Other Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Ambulance Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Diagnostic Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Durable Medical Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Hospice Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

If You Get a Bill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Member Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Member Rights and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Members’ Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Members’ Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Complaints and Grievances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Appeals Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Definition of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32


HOW THE PLAN WORKSUS Family Health Plan (USFHP) is a managed care plan. It is designed to provide full medical benefits at a low out-of-pocket cost. A managed care plan relies on a primary care provider, or PCP. The PCP may be a pediatrician, family practitioner, internist, doctor of osteopathy (DO), advanced registered nurse practitioner (ARNP), or physician’s assistant (PA). The PCP arranges all your healthcare needs with specific providers and hospitals.

Payment for these services is handled by the Plan. Except during an emergency or if you get preapproval from the Plan, covered benefits are available only from Plan providers. There are no claim forms when you use providers who are approved by the Plan. You are responsible only for the copayment, if one applies.

This is a TRICARE Prime® option. TRICARE® is a health insurance plan that is sponsored by the Department of Defense (DoD). It is for eligible military beneficiaries.

The Plan provides or arranges for your care and pays the cost of all authorized services. So the Plan makes every effort to deliver care efficiently and effectively. The Plan tries to avoid unnecessary or inappropriate care. In this way, the DoD can afford to offer a broader range of services. Examples of these services include mammograms and immunizations. The Plan provides comprehensive healthcare services and benefits for accidents, illness, and injury. It also emphasizes preventive services.

GETTING STARTEDEach person covered by US Family Health Plan gets a member ID card. Present this card when you get medical services. It is a good idea to carry your card (and your chil-dren’s cards) with you, in case of an emergency. Please take a moment to look at your card and check that the information is correct. If it is wrong, call Member Services. We are at 1 (800) 585-5883. If your card is lost or damaged, please call and ask for a replacement.

Before you get care, always identify yourself as a USFHP member. Present your USFHP card at the beginning of all appointments. Present it when registering at a facility or emergency room. And show your card before starting a new relationship with a provider or facility.

To receive coverage, you must transfer your care to Plan-approved providers. Your pri-mary care provider will help you to transfer your care and records to the Plan. Remem-ber that in order to be covered, all outside services must be coordinated by your PCP.

ELIGIBILITYTo enroll in the Plan, you must be an eligible beneficiary of the Military Health System. You also must live in the USFHP service area. The service area is defined by ZIP codes, and it includes most of the Puget Sound area. You must also be registered in the Defense Enrollment Eligibility Reporting System (DEERS). DEERS must show that you are eligible to receive healthcare benefits. DEERS must also show that you have a


valid military ID. To maintain your coverage, keep your DEERS record up-to-date. If you have any questions about DEERS, call 1 (800) 538-9552.

Eligible beneficiaries include the following:• Husbands and wives. Unmarried dependent children of active duty sponsors.

NOTE: Children are eligible until their 21st birthday, or their 23rd birthday if full-time students.

• Retirees. Their spouses or survivors. Their unmarried dependent children.• Eligible former spouses of active duty or retired service members.• When active duty or retired service members have died: Their unmarried

spouses. Their qualified unmarried children. • With National Oceanic and Atmospheric Administration (NOAA) members:

Those who retired before July 19, 1963. Those who have had continuous service starting before that date.

• Family members of NOAA members listed above.• Retired lighthouse keepers and their family members.• Those who have received a Medal of Honor.• Family members of reservists who have reactivated and are qualified.• Retired reservists as of their 60th birthday.

NOTE: Members who disenroll after age 65 will not be allowed to reenroll.

What if you are an inpatient on the date your coverage is scheduled to begin? Your coverage will not be effective until the date you are discharged from the hospital or other facility.

What if you are an inpatient on the date your coverage is scheduled to end? Your coverage will continue until the date of your discharge. Coverage will be for facility charges only.

Active duty sponsors are members of the uniformed services. Their dependent family members are eligible to enroll in USFHP; the sponsors are not. Active duty sponsors are enrolled automatically in TRICARE Prime. They get care at the Military Treatment Facility. (They might be enrolled in TRICARE Prime Remote, if appropriate.)

To keep receiving USFHP benefits, family members must keep their military ID cards up-to-date. They must also keep their DEERS eligibility up-to-date.

Changes Affecting EligibilityEnrolled families sometimes add new members. Examples are newborn children, adopted children, or a new spouse. These new family members may join the Plan at any time during the enrollment year.


Additions to Your FamilyIf your family has a birth or legal adoption, you must complete a new application for the addition. You must apply within 60 days of the addition. You can enroll the new born by phone or submit an enrollment form. Just call 1 (800) 585 5883.

Newborns are conditionally covered under the Plan. New babies must be reported to the Enrollment department within 60 days of birth. They must also be enrolled in DEERS within 60 days of birth. If this does not happen, coverage will be terminated; the termination will be effective on the sixty-first (61st) day.

Change of AddressPlease send your new address to:

US Family Health PlanEnrollment Management1200 12th Avenue S, Qtrs 8/9Seattle, WA 98144

The USFHP service area is defined by ZIP codes. It includes most of the Puget Sound area. If you move to another area, it may be covered by another branch of USFHP, and you may be able to transfer your USFHP coverage. Call the Enrollment department to discuss your options at 1 (800) 585 5883.

What if you move out of the USFHP ZIP-code-defined service area? You will no longer be eligible for coverage under the Plan. You must disenroll to reinstate full TRICARE or Medicare benefits. If you move to an area where TRICARE Prime is available, we recommend you transfer your enrollment. See “Enrollment Portability” if you are under 65 years old. See “Disenrollment” if you are over 65 years old.

ENROLLMENT IN US FAMILY HEALTH PLANOnce accepted in the Plan, the beneficiary will not need to reapply. Membership will be renewed automatically each year unless you elect a different option or disenroll during the open enrollment season. Membership will not be renewed if the beneficiary’s eligibility changes. It also won’t be renewed if he/she moves out of the area or fails to pay applicable enrollment premiums.

Members under age 65 who join the Plan after October 1, 2012, will be automatically disenrolled at age 65.

NOTE: Are you an active duty family member whose sponsor is planning to retire? If you want to continue in the Plan, you must tell the Enrollment department. If your sponsor retired and you haven’t paid your enrollment premium since the retirement date, you will be disenrolled automatically. Your disenrollment date will be set back to your sponsor’s retirement date.

Enrollment PremiumsMilitary retirees and their family members without Medicare Part B must pay an enrollment premium. Survivors of retirees without Medicare Part B must also pay an


enrollment premium. There is no enrollment premium for active duty family members. There is no enrollment premium for members with Medicare Part B. The enrollment premium is payable at the time of enrollment in the Plan.

You may pay your enrollment premium in one payment, or in monthly or quarterly installments. If you pay in one payment or each quarter, you can call US Family Health Plan to make payment by phone free of charge. Visa, MasterCard and Discover debit/credit cards are accepted. Not accepted are cash, checks, online bill pay checks and money order.

Starting January 1, 2018, military beneficiaries will fall into one of two categories based on when you or your sponsor entered active duty. Each group may have different enrollment fees and out-of-pocket costs. If you or your sponsor’s initial enlistment or appointment occurred before January 1, 2018, you are in Group A. If you or your sponsor’s initial enlistment or appointment occurs on or after January 1, 2018, are in Group B.

Also starting in November 2018, enrollment will be done only during an open enrollment season prior to the beginning of each plan year, which operates with the calendar year. An enrollment will be effective with the plan year. Beneficiaries may choose to enroll, change or terminate Prime coverage during the open enrollment period. Enrollment may be on an individual or family basis. Beneficiaries may change between Prime plans throughout the year. US Family Health plan is considered a Prime plan.

As an exception to the open enrollment season rule , enrollment can be made during the plan year for certain Qualifying Life Events (QLE), including:

• Birth or adoption of a child by a court in a member home• Change in sponsor status• Relocation to a new country region or zip code service area• Loss or gain of Other Health Insurance (OHI)• Death of a sponsor, spouse or child• Change in eligibility status of any single family member in another family

Enrollment must be within 90 days of the date of the QLE. Coverage starts as of the date of the QLE. Applicable enrollment fees must be paid for that period. A QLE for one beneficiary in a sponsor’s family permits a change in the sponsor’s or other family member’s enrollment status during the QLE period.

Enrollment Premium AmountsFor current enrollment premiums, call USFHP Enrollment Department. The number is 206-621-4568.

The National Defense Authorization Act determines some aspects of TRICARE Prime. The Act for fiscal year 2012 allows for annual increases of enrollment premiums for most retirees. These increases are based on the annual adjustment for cost of living. Two groups are exceptions and do not get these increases. They are the survivors of active duty sponsors and medically retired members, and their dependents. Group B


beneficiaries are not included in this exception.(see page 7: Enrollment in US Family Health Plan).

Are you eligible for Medicare? And are you currently enrolled in Medicare Part B? If so, your portion of the enrollment premium will be waived; you must submit a copy of your Medicare card showing Part B coverage. Should you become eligible for Medicare while enrolled in the Plan, please submit a copy of your Medicare card showing Part B cover-age to the Enrollment department. If you are paying enrollment premiums, they will be prorated for the rest of the enrollment year.

Whenever possible, all family members should be enrolled at the same time. Payment of the applicable premiums should be made in accordance with Department of Defense requirements.

Quarterly Payment of Enrollment PremiumsIf you pay your enrollment premium on a quarterly basis, please remember the following:

1. You will receive a bill 30 days before your next quarterly due date.2. If you fail to pay on time, you will be subject to disenrollment. You will be respon-

sible for certain costs for any care received after the termination date. In 2018, these costs are the deductible and cost shares applicable under TRICARE Select.

Split EnrollmentSplit enrollment means that family members are enrolled in TRICARE Prime/USFHP under different contractors. Where each family member is enrolled does not affect enroll-ment premiums; the family’s premiums are the standard premium. If your family has a split enrollment, be sure to give the enrollment office in each TRICARE region proof that your enrollment premium has been paid. This will ensure that you pay your premiums only once per family. You also must keep track of your family’s combined costs toward the catastrophic cap. Please notify us when your family’s combined payments have met or exceeded the cap. (Read more about the catastrophic cap on page 23.)

Enrollment PortabilityIf you move, your new address may make you eligible for different TRICARE options. Contact Health Net Federal Services(HNFS) at (1-844-866-9378) to learn about your options. HNFS can tell you if TRICARE Prime is available there and if you can transfer your coverage to it.

You can transfer your enrollment to US Family Health Plan online, by mail, or by phone. If you mail a paper application, your enrollment takes effect the day the application is received. If you enroll online, your enrollment takes effect after you submit your request. The website is: www.hnfs.com/content/hnfs/home/tn/bene/enroll/tools/bwe.html. If you move to an area served by a different USFHP contractor, you can transfer your enrollment. Please contact that contractor’s office to start the transfer process. If TRICARE Prime is not available in your new area or you prefer to use TRICARE Select, you must disenroll from US Family Health Plan. (See Disenrollment).


Online Enrollment for BeneficiariesYou can enroll in US Family Health Plan over the Internet. Just use the TRICARE Beneficiary Web Enrollment (BWE) site. You also can go there to make changes to your DEERS account. To access the BWE site, visit www.usfhpnw.org. Click on the link labeled “Enroll in USFHP Now.”

To log on to the BWE site, you must have one of the following:

• Valid Certified Common Access Card (CAC)• Defense Financial and Accounting Services (DFAS) myPay login ID and password• Department of Defense Self-Service Logon

You may also use this site to:

• Enroll or transfer enrollment• Update contact information in DEERS• Edit or update address• Make initial credit card payment• Convert enrollment from active duty to retiree status up to 60 days before

retirement (DEERS must reflect retirement status)• Add information about other health insurance to your DEERS record• View enrollment information

TRICARE YOUNG ADULT US Family Health Plan offers a TRICARE Prime option under the TRICARE Young Adult (TYA) Program. Eligibility for regular TRICARE ends at age 21. After that, the TYA Program can be purchased. (The age may be 23 if the person is enrolled in a full course of study. He or she must be at an approved institution of higher learning.) TYA is an individual healthcare plan, and you must pay monthly premiums. It provides full health insurance that includes medical and pharmacy benefits. This program gives young adults the opportunity to continue their TRICARE healthcare coverage. It is valid as long as their sponsor is eligible for TRICARE.

You are eligible to purchase TYA coverage if you are all of the following:

• A dependent of an eligible uniformed service sponsor• Enrolled in the Defense Enrollment Eligibility Reporting System (DEERS)• Unmarried• Over age 21, or over age 23 if enrolled as a full-time student—up to age 26—

and your military sponsor provides at least 50% of your financial support• Not eligible to enroll in an employer-sponsored health plan based on your own

employment• Not eligible for any other TRICARE program coverage

Eligibility for this program ends at age 26 or when any of the above conditions are no longer met.


DISENROLLMENTYou can disenroll from USFHP by choice. In 2018, contact the Managed Care Support Contractor in your area to change your coverage . After 2018 you must wait until the open enrollment season to make a change. An exception is if you have a Qualifying Life Event .(See Enrollment, page 7) or if you transfer to TRICARE Prime. You will be disenrolled automatically if you move out of the area. You also will be disenrolled if your eligibility status changes in DEERS or you fail to pay applicable enrollment premiums. If you are disenrolled for non-payment of your enrollment premium, you may reinstate coverage with the payment of all past due enrollment premiums within 90 days of the end of the last paid-through date. You may reenroll in USFHP, TRICARE Select or TRICARE Prime in 2018. After 2018, you will not be able to reenroll in any TRICARE option until the next open enrollment season which starts in November. Members who disenroll after age 65 will not be allowed to reenroll. To disenroll, you must submit your request in writing. Submissions can be either by fax or mail.

US Family Health PlanEnrollment Department1200 12th Avenue S, Qtrs 8/9Seattle, WA 98144Fax: (206) 326-2458

Are you acting on behalf of a family member through a Durable Power of Attorney (DPOA)? Your signature and a copy of the DPOA are required with the letter.

Federal regulations apply. Members can be disenrolled if they use Medicare to get covered services from any provider. Your coverage will be ended in several other instances: 1) If you provided false information to the Plan. 2) If you committed fraud with respect to the Plan. 3) If you permit someone else to commit fraud. 4) You use the Military Treatment Facility services without authorization. Your coverage will be ended at midnight on the date it is determined one or more of these rules occurred in keeping with guidelines of the law.

TRICAREBy enrolling in USFHP, you have agreed to receive your healthcare through the Plan. The Department of Defense (DoD) has required, as a condition of membership, that you agree not to use your other TRICARE Plan options.

OTHER INSURANCE AND INSURANCE CHANGESThe Plan requires that you report other health insurance that you are enrolled in. This includes insurance through your employer and Medicaid insurance provided by the state. Please call Enrollment Management at 1 (800) 585-5883 to report other insurance. While enrolled with USFHP, you must cancel your Federal Employee Health benefit (FEHB) insurance. Please contact Office of Personnel Management (OPM) at 1-888-767-6738 regarding canceling FEHB coverage.


COORDINATION OF BENEFITS (COB)The contract between USFHP/TRICARE Prime and DoD dictates how to bill if you have more than one insurance. If you have other comprehensive health insurance, it must be billed first. After your other insurance pays, USFHP will pay any eligible balance up to the allowable charge.

Third-Party LiabilityIf you are hurt in an accident, another party may be liable for your medical costs. Acci-dents of this type can involve a motor vehicle or a consumer product. They also include accidents like slipping and falling.

Each branch of the military is entitled to reimbursement from the party that is liable. This includes any insurance plan that might cover you. One example is auto insurance for uninsured drivers. You, or your representative or beneficiary, must take all needed steps so that the Plan can exercise its rights. This includes completing and sending all documents.

If you get care for injuries sustained in an accident, call USFHP. Tell the Plan whether or not you intend to seek compensation. Ask for an Accidental Injury/Third Party Liabil-ity Questionnaire and DD Form 2527. You may reach USFHP at 1 (800) 585-5883.

Work-Related InjuriesIf you have a work-related injury you must file a claim with the Department of Labor & Industries.

Medicare Eligibles: If You Are 65 or OlderIndividuals with Medicare Part B coverage have no annual enrollment premium for USFHP. They also have no copayments for covered services. However, they do have copayments for prescriptions.

If you are 65 or older and enrolled in the Plan, you may not use your Medicare benefits for services covered by USFHP. This rule helps avoid duplication of coverage under government-sponsored programs. Members are not allowed to enroll in Medicare- sponsored managed care plans (HMOs) while enrolled in USFHP. Using Medicare ben-efits for covered services is grounds for disenrollment from the Plan. The only excep-tions are chiropractic care, which is not covered by USFHP, and if you are enrolled in the End Stage Renal Disease (ESRD) Program through Medicare. The Medicare ESRD program is primary to USFHP.

Even though you are now a Plan member, you are advised to continue your Medicare Part B coverage. By keeping it, you can avoid penalties or waiting periods if you choose to leave the Plan and use your Medicare benefits. What if you become eligible for Medicare during the Plan year? You are advised to accept Medicare Part B coverage when first eligible. This way, you will avoid waiting periods and penalties for late Part B enrollment if you later want to leave the Plan and use Medicare. Retirees with current Medicare Part B are not required to pay copayments (except pharmacy). They also do not pay enrollment premiums. Once the enrollment office receives proof of your Medi-care Part B, then your enrollment and copayments are waived.


THE ROLE OF YOUR PRIMARY CARE PROVIDER (PCP) As a member of the Plan, you will establish a relationship with a primary care provider. Your PCP will get to know you, your medical history, and your individual healthcare needs. Your PCP sees you for all of your routine health needs and maintains your medical records. Your PCP also monitors your medications and orders tests or services like physical therapy. If you have a complex problem, your PCP may refer you to one of USFHP’s many qualified specialists. Your PCP and the Plan specialist will work together as a team to meet your healthcare needs.

The advantage of having a PCP to provide or manage most of your care is simple. You have someone to call when you need care. And there’s coordination of care between your PCP and your specialists, hospital, and other facilities. Your medical records are in one place, including your prescriptions. You have someone who helps you navigate the complex world of healthcare. And your PCP takes care of the paperwork, so you don’t have to file claims.

CHOOSING YOUR PRIMARY CARE PROVIDERThe first and most important decision each member must make is the selection of a PCP. Each enrollee in your family should select a PCP with whom he or she is comfort-able. Family members do not need to select the same PCP, and their selections may be changed upon request.

The Plan’s primary care providers include pediatricians, family practitioners, internists, doctors of osteopathy (DO), advanced registered nurse practitioners (ARNP), or physi-cian’s assistants (PA). A list of PCPs can be found online at www.usfhpnw.org. You will see their locations and phone numbers and can choose a PCP close to home or work.

PCP lists are subject to change and are updated on a regular basis. You may check the status of any PCP. Just call US Family Health Plan Member Services. Or visit our website at www.usfhpnw.org.

THE REFERRAL PROCESSUSFHP pays for covered medical services when they’re provided by your PCP or autho-rized in advance by the Plan. Think of your PCP as the person who guides you to other healthcare providers. These might include specialists, hospitals, and rehab facilities. For example, if you need to see a heart specialist, your PCP will give you a referral to a cardiologist. Once that referral request is authorized by the Plan, you can call your specialist for an appointment. Call Member Services for the status of your referral authorization if you have not received it by mail.

The only services for which you do not need a referral in advance are:• Office –based outpatient behavioral health visits• Emergency care• Routine annual mammography• Routine annual eye exam


NOTE: If you receive healthcare services that are not authorized by USFHP, you will be covered under the Point of Service (POS) benefit. (Emergency services are an excep-tion.) If you decide to use the POS benefit, you will be responsible to pay the deductible and cost shares. Please see a more detailed description of the POS benefit on page 15.

THE REFERRAL NETWORKYour PCP will refer you to specialists and other medical professionals who are also connected with the Plan. We call this group the “referral network.” This system ensures better communication. It also ensures good coordination of care between your provid-ers. If the specialty care you need is not available within the referral network, your PCP will refer you elsewhere. When both your PCP and the Plan authorize you to get care outside of the referral network, it is covered by the Plan.

ABOUT REFERRALS TO SPECIALISTSYour referral must be approved by the Plan. A referral authorization will be mailed to you and to the referring provider.

Authorizations are valid only for the diagnoses indicated. They also are valid only for the services indicated. Authorizations have an expiration date. You cannot use them after that date, no matter how many visits are indicated. It is very important that you keep track of the number of visits authorized. Also keep track of how many times you have seen the specialist. And keep track of the referral’s expiration date.

Sometimes you need more visits with the specialist than those authorized by your refer-ral. In that case, you must get another referral for the extra visits. Also, suppose the specialist wants you to see another specialist or get other services. You must first get authorization from your PCP.

Plan authorization is required for certain referrals. Some medical services have a limited benefit. Examples are oral surgery and sleep studies. These types of services need to be reviewed first to make sure that they are covered by the Plan. Suppose you are referred to a provider or facility that is outside the network. The referral must be reviewed for authorization. The Plan will see if that particular service could be provided inside the network. If authorized, you will receive your copy of authorization in the mail. It typically will arrive in 7 to 10 business days. Important: USFHP benefits apply only to covered services that are provided by your PCP or authorized in advance by the Plan. If your referral is denied, you will receive a denial letter with alternative recommenda-tions and a description of the appeal process.

HOSPITAL SERVICESIf a member is hospitalized by a Plan provider, USFHP has a full range of hospital benefits. Active duty family members and retirees with Medicare Part B have no copay-ment. All others have a per admission charge of $150. All medically necessary services are covered, including the following:


• Semi-private room accommodations (a private room may be covered if a Plan provider determines it is medically necessary)

• Specialized care units, such as intensive care or cardiac care units• Physician services related to medical treatment or surgery• General nursing services• Operating room, anesthesia, and supplies• Prescribed inpatient drugs• Inpatient physical therapy and rehabilitation at the appropriate level of care• Other medically necessary supplies and services• Inpatient treatment for mental health care and substance use disorder

If You Are Admitted to a HospitalIf you must be hospitalized, your PCP or specialist will make the arrangements for you. All members must use the inpatient facilities that are affiliated with their PCP.

NOTE: If you are admitted to a hospital as an emergency, your PCP must be notified. This must happen within 24 hours or within the next business day.

POINT OF SERVICE (POS) OPTIONThe Point of Service option lets USFHP members seek covered, non-emergency healthcare services from any TRICARE-authorized provider without a referral or authorization.

Point of Service CostsUsing the Point of Service option can be very expensive. The patient is financially responsible for:

• An annual (fiscal year) outpatient deductible of $300 per individual; $600 per family

• A large cost share of TRICARE allowable charges • Outpatient—50%, after the deductible is met • Inpatient—50%, after the deductible is met• Additional charges may apply when using non-network providers • Up to 15% above the TRICARE allowable charge is permitted by law • Point of Service charges do not apply toward the annual catastrophic cap, so

there is no upper limit as to how much the patient may be responsible for

Point of Service ExclusionsThe Point of Service option does not apply to the following:

• Newborns or adopted children for the first 60 days • Emergency care • Covered preventive care services from a network provider • When the patient has other health insurance


MILITARY TREATMENT FACILITY PRIVILEGESAs a condition of membership, your use of military treatment facilities is limited. You may not use these facilities for non-emergency care. You may not get prescriptions filled there. However, if you experience an emergency that threatens your life or a limb, you may use the nearest emergency facility. It can be a civilian or military facility. You must notify your primary care provider within 24 hours of receiving care. Claims for emer-gency treatment should be submitted to the Plan for payment.

UTILIZATION MANAGEMENT AND CASE MANAGEMENTWe provide medical care in the best setting for your symptoms or condition. At the same time, we use medical resources efficiently. These are important ways that we manage care. For example, care will be given on an outpatient basis, unless inpatient care is necessary.

When it is not an emergency, the Plan will consider hospital admissions in advance. This is to make sure that inpatient care is appropriate. The Plan must also authorize certain outpatient surgery and diagnostic services. The program reviews treatments and handles authorizations. The guidelines used are nationally accepted.

US Family Health Plan has a case management program. Case managers work closely with PCPs to coordinate care for individuals who have medically complex conditions.

If you have any questions regarding the preauthorization approvals for your upcoming scheduled admission or outpatient surgery, call Member Services. We are at 1 (800) 585-5883.

Medically Necessary CareAs a USFHP member, you have many benefits. The utilization management process helps ensure that you receive all the benefits to which you are entitled. It is also intended to make sure that the Plan pays only for care that is medically necessary.

Medically necessary care is defined as service or supplies provided by a hospital, physi-cian, or other provider for the prevention, diagnosis, or treatment of an illness, when those services or supplies are determined to be:

1. Consistent with the condition, illness, or injury of the patient.2. Provided in accordance with the approved and generally accepted medical or

surgical practice. That practice must prevail where and when the service or supply is ordered.

3. Delivered in the most appropriate healthcare setting.

Extended Care Health Option (ECHO)The Extended Care Health Option adds to the basic TRICARE program. ECHO provides financial help for a set of services and supplies. It is available to eligible active duty family members. This includes family members of activated National Guard or Reserve members.


There is no enrollment premium for ECHO. However, family members must:

• Be enrolled in the Exceptional Family Member Program (EFMP). This is through the sponsor’s branch of service.

• Have an ECHO-qualifying condition.For more information, please call Member Services. We are at 1 (800) 585-5883.

EMERGENCY CAREWhen a medical emergency threatens a life, call 911 or your local emergency num-ber. Or go to the nearest emergency room (ER) right away.

The Plan covers emergency care for conditions that threaten a life, limb, or sight. The Plan defines an emergency as a condition that a prudent layperson expects may do any of the following:

• Place the patient in serious danger• Seriously harm their body functions• Seriously harm their organs

(The layperson is not an expert but has an average knowledge of health and medicine.)

These conditions are sudden and unexpected. They require immediate attention. Examples of life-threatening emergencies include:

• Severe chest pains• Difficulty breathing• Loss of consciousness• Poisoning

Examples of conditions that are not life threatening include:• Sprains or strains• Illnesses such as respiratory infections or chicken pox• Backaches, earaches, or sore throat

NOTE: If you are not sure whether your condition is a true emergency, call your clinic first.

Contact your primary care provider as soon as possible. Your PCP will provide and coordinate follow-up care such as X-rays or removal of stitches. Do not return to the emergency room for follow-up care unless your PCP refers you there.

Notify the Plan about your emergency room visit. Be sure to call within 24 hours or within the next business day of when you receive care. Call 1 (800) 585-5883.

AFTER-HOURS SERVICESIf you have a medical problem during clinic hours, you should call your clinic. After regular hours, call your clinic number to reach the after-hours service. The clinic’s after-hours service will help you get the care you need for medical problems that re-quire prompt attention.


IF YOU ARE TRAVELINGSuppose you are traveling and you are outside the Plan service area (Puget Sound). If you become ill and need urgent care (non-life threatening), call your primary care phy-sician to have your care authorized and coordinated. If it is after hours, call your clinic’s main number to reach the after-hours service. If you have a life- or limb-threatening emergency, seek care as soon as possible. Be sure to notify the Plan within 24 hours or within the next business day of when you receive care. If you are asked to pay at the time of service, make sure to get an itemized statement from the provider. When you return to the coverage area, you can request to have your money reimbursed.

Suppose you are outside of the United States (OCONUS) and have an emergent or urgent situation. Get care. Then be sure to submit your bills, receipts, and treatment information to Member Services within seven days of return to get reimbursed. If you fail to notify us within the required time period, you may be responsible for the cost of your care.

REMEMBER: Routine or unapproved follow-up care received outside of the service area is not covered.

SUMMARY OF BENEFITS CHARTThis chart shows a summary of healthcare services your family may need. The services are covered by the Plan as long as your USFHP primary care provider (PCP) provides or authorizes them. It is important to understand how to take advantage of your coverage and get the care you need. This will help you avoid unnecessary costs or paperwork.

SUMMARY OF BENEFITS

COVERED SERVICES

Co-Pay for Active-Duty Family Members

and Retirees With Medicare Part B

Co-pay for Retirees, Survivors

& Family Members Without Medicare Part B

Group A Group B Group A Group B

Annual Physical $0 $0

Primary Care Visit $0 $20

Specialty Care Visit $0 $30

Urgent Care Center Visit $0 $30

Emergency Room Visit $0 $60

Ambulatory Surgery $0 $60

Inpatient Hospital $0 $150 per admission

Skilled Nursing Facility $0 $30 per day

Ambulance Service:

Ground $0 $40

Air $0 $20

Inpatient Non-network Transfer $0 25% of allowable charge

Durable Medical Equipment $0 20%

Physical Therapy $0 $30

Occupational Therapy $0 $30


Rehabilitation Therapy $0 $30

Routine Pap Smear $0 $0

Routine Immunizations (except travel)

$0 $0

Well-Child Care & Immunization (up to 6 years old)

$0 $0

Maternity (hospital & professional services, pre-natal)

$0 $150 per admission

Routine Eye Exam $0 $0

Behavioral Health:

Outpatient Behavioral Health Visit Individual & Group

$0 $30 per visit

Inpatient Mental Health $0 $150 per admission

Residential Treatment Facility (mental health & substance use disorder [SUD], inpatient or partial day)

$0 $30 per day

Catastrophic Cap $1,000 $3,000 $3,500

Point of Service $300 per individual or $600 per family, + 50% of TRICARE allow-able charge

ExclusionsUS Family Health Plan follows TRICARE policy for coverage and exclusions. For the current list, visit www.tricare.mil and search for Exclusions in the Covered Benefits section.

The following specific services are excluded under any circumstance:

AcupunctureAny services provided for education, employment, licensing, immigration, elective travel, or other administrative reasonsArtificial insemination, including in vitro fertilization, gamete intrafallopian trans-fer, and all other such reproductive technologiesAutopsy services or post-mortem examinationsAversion therapyBed-wetting corrective devicesBirth control/contraceptives (non-prescription)Camps (for example, weight loss, diabetes, etc.)Care or supplies furnished or prescribed by an immediate family memberCare or treatment as a result of being engaged in illegal occupation or commission of, or attempted commission of, a felony or assaultCharges for missed appointments, telephone consultations, or the completion of medical reports or certification servicesChiropractic services


Complications due to non-approved or non-covered procedureConvalescent care and/or custodial careCosmetic, plastic, or reconstructive surgery not connected to medical treatmentDental X-rays and services, dentures, and orthodontiaEducation or trainingElectrolysisExperimental or unproven proceduresEyeglasses, frames, and contact lenses (limited exceptions)Foot care (routine), except if required as a result of a diagnosed, systemic medical disease affecting the lower limbs, such as severe diabetesGym membershipHearing aids (limited exceptions)Learning disorder, dyslexiaMassage therapyMedications: • Drugs prescribed for cosmetic purposes• Fluoride preparations• Food supplements• Homeopathic and herbal preparations• Multivitamins• Over-the-counter products (except insulin and diabetic supplies)• Weight reduction products

Life coachNaturopathic careOrthopedic shoes and arch supports, except when a part of a brace (limited exceptions)Radial keratotomy, Lasik or other elective visual corrective surgeryRespite care (limited exceptions)Retirement homes, assisted living facilities, and domiciliary homesServices and drugs not prescribed or authorized by your primary care provider (PCP) or a specialist to whom you were referredServices not considered medically necessary for your diagnosis; and treatment provided at an inappropriate levelSex changes or sexual inadequacy treatment, with the exception of treatment of ambiguous genitalia that has been documented to be present at birthSterilization reversal surgeryVisual training


This summary is not an all-inclusive list. Complete details of benefit coverage and exclusions are available by calling Member Services at 1 (800) 585-5883. The benefits and costs outlined in this Handbook are accurate as of the date of printing but are subject to change by the Department of Defense.

PHARMACYAs a USFHP member, getting your prescriptions filled is convenient and easy. US Family Health Plan has a network of retail pharmacies where members can get up to a 30-day supply. Or you can place your order through mail-order and receive up to a 90-day supply.

Filling Your PrescriptionIf you are new to the Plan, talk with your new provider about rewriting your prescrip-tions. Then they can be filled either at your USFHP network pharmacy or through mail-order.

You can set up a mail-order account by calling Maxor Mail-Order. Their number is 1 (866) 408-2459. You will want to make sure that they have the correct mailing address and payment information.

Services and LocationsUS Family Health Plan has an extensive pharmacy network for its members. To find a pharmacy that’s convenient for you, please visit us online. Go to www.usfhpnw.org. Click on the “Members” section, and then on “Prescriptions.” Or call Member Services at 1 (800) 585-5883.

Ordering medications by mail is the most cost-effective option for USFHP members. Our service is managed by Maxor Mail-Order. Maxor is in Amarillo, Texas. It delivers medica-tions directly to your door. Call Maxor for refills and to update your payment accounts. You may also call Maxor for answers to questions about a medication. The mail-order phone number is 1 (866) 408-2459. Please note that prescriptions will not be mailed until you have paid your copayments. We strongly suggest that you set up an automatic payment method for your copays.

NOTE: No prescriptions can be filled at a Military Treatment Facility.

Prescriptions for After HoursFor urgent/emergent needs after hours and on weekends in the Puget Sound area, you may use Bartell Drugs, a Safeway pharmacy or Rite Aid.

If you cannot access one of these pharmacies, you may use any drugstore nearest you. You will need to pay up-front for the medications at these other pharmacies. To get reimbursed, you must submit the receipt for the prescription with a brief explanation of what happened. The receipt should show the patient’s name, drug name, quantity dispensed, and amount paid. The receipt will sometimes have the wording “Official receipt, retain for insurance.” If you have not obtained this information, we suggest you call the number on the register tape and request the pharmacy release the prescription information to us via fax.


Prescriptions When Traveling out of the AreaMaxor Mail-Order can mail your prescriptions anywhere in the United States. If you are going to be away from home, call Mail-Order in advance. Allow 14 days for delivery. The number is 1 (866) 408-2459. Ask them to set up an alternative mailing address for delivery. The address must be within the United States.

If you receive emergency or urgent care while traveling, you might be prescribed a new medication. In that case, you can use a Rite Aid pharmacy and pay applicable copay-ments. If Rite Aid is not close by, use the nearest pharmacy and pay the full out-of- pocket cost. Be sure to save your receipts and send them to US Family Health Plan. You will be reimbursed for the amount you paid, minus any applicable copays.

CopaymentsThe following copayments (“copays”) apply to each prescription fill:

Copay Tier Pharmacy Cost Rx per Fill* Cost Rx per Year

Tier 1 Formulary Generics

Mail-Order $7 $28

Local Pharmacy

$11 $132

Tier 2 Formulary Brands

Mail-Order $24 $96

Local Pharmacy

$28 $336

Tier 3 Non-Formulary

Mail-Order $53 $212

Local Pharmacy

$53 $636

* Retail is for up to a 30-day supply per fill. Mail-Order is for up to a 90-day supply per fill.

** A drug formulary is a list of generic and brand name drugs that are preferred by a health plan. Drugs on the TRICARE formulary are covered in whole or in part. TRICARE regularly reviews drugs for their clinical and cost effectiveness. Non-formulary drugs are not on the list and have a higher copay.

For one copayment, patients can get up to a 90-day supply through Mail-Order. At local pharmacies, patients are limited to a 30-day supply for one copay. If you have main-tenance medications, you can save money by using Mail-Order for refills. It can cost one-third less than local pharmacies.

Prescription Drug Limitations and ExclusionsSome specific medications are limited as to how much can be dispensed at a time. These limits are put in place largely to avoid the overuse of a drug. They also help us all avoid wasting medications.

The Plan will not provide coverage for:• Brand-name medications if the drug is available generically. (Exceptions can be

made in specific circumstances.)• Drugs used for cosmetic reasons. This includes but is not limited to drugs used

for hair growth or for wrinkles.


• Products that don’t need a prescription. (A few limited exceptions are covered when prescribed by a physician and filled through the pharmacy.)

• Medical supplies, such as dressings and antiseptics.• Other prescription drugs not covered under the TRICARE benefit.• Prescriptions written by physicians not affiliated with USFHP. An exception is

when your USFHP provider writes a referral to that physician or as required for emergency care as determined by the Plan.

• Drugs obtained at a non-Plan pharmacy, except in an out-of-area emergency.

CATASTROPHIC LOSS PROTECTION BENEFIT (CATASTROPHIC CAP)As USFHP members, your family has a catastrophic loss protection limit for your health-care costs. (It is also called a “catastrophic cap.”) This means there is a limit to your out-of-pocket expenses.

The catastrophic cap varies. For active duty family members, it is $1,000. For Group A retirees, their family members, and survivors, it is $3,000. For Group B retirees, their family members and survivors, it is $3,500. In all cases, the cap is per enrollment year and per family. The enrollment year is based on the 12-month enrollment period. Several expenses that you pay out of your own pocket contribute toward your cap. These include copayments and cost shares. Once you meet your catastrophic cap, your family will not have to pay any more out-of-pocket costs for the rest of that enrollment year.

USFHP encourages you to keep track of your out-of-pocket expenses. Compare your record to what the Plan credits toward your cap. If you find a discrepancy, please send a copy of your receipts to:

US Family Health PlanMember Services1200 12th Avenue S, Qtrs 8/9Seattle, WA 98144

OUTPATIENT SERVICESAt US Family Health Plan network clinics and through the referral network, the follow-ing services are covered:

• Office visits to your primary care provider (PCP).• Prescription drugs.• Authorized office visits to Plan specialists. Your PCP must refer you.• Preventive health services. This includes well-baby, well-child and

well-adult care.• Covered outpatient surgical procedures and anesthesia. Your PCP must

refer you.• After-hours services at a Plan clinic or designated facility when authorized.• Maternity (prenatal and postpartum) care. Newborn care.


• Routine eye exams.• Emergency room visits for a medical emergency or when authorized by the Plan.

BEHAVIORAL HEALTH AND SUBSTANCE ABUSEWhat Is Covered The Plan provides services to diagnose and treat psychiatric conditions. The services must be needed for medical or psychological reasons. If you need help with a behavioral health facility referral, please call your primary care provider. Services include:

• Evaluation to determine a diagnosis.• Psychological testing.• Psychiatric treatment. (This includes individual and group therapy.)• Hospitalization. This service is subject to medical review. (It includes profes-

sional services in an inpatient setting.)

USFHP patients can self-refer for outpatient (office-based) behavioral health visits from a TRICARE authorized provider without a referral from their primary care provider. A referral authorization is required for facility-based behavioral health and substance abuse services.

The Plan covers treatment for chemical or alcohol dependency. It must be provided at an approved facility. It can be an inpatient or outpatient facility.

The Plan only covers approved services from TRICARE authorized provider. If you are now being treated for behavioral health by a non-Authorized provider, you should call your PCP. Ask the PCP to transfer your care to a Plan provider. The same goes for out-side treatment of chemical and alcohol dependency.

SKILLED NURSING CAREInpatient Skilled Nursing CareUSFHP provides skilled nursing care when it is necessary for medical reasons. Care is provided in a contracted nursing home. The nursing home is accredited. Coverage includes:

• Bed, board, and skilled nursing services. This is in a sub-acute or rehabilitation facility.

• Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the facility. These must be authorized by a Plan provider.

• Other treatments and services. They must be medically necessary. They must be deemed appropriate.

NOTE: Short- or long-term custodial care is not covered.


Home CareThe Plan provides home care when it is necessary for medical reasons. This may include:

• Durable medical equipment. It must be arranged by the Plan. Examples are wheelchairs, hospital beds, oxygen, and respirators.

• Physical, speech, or occupational therapy at home. These are covered only for short, defined periods. These are covered only when big improvements can be expected.

NOTE: Home care is covered only when some rules are followed. It must be medically necessary. It must be authorized by the Plan. Finally, it is limited to skilled services. Assistance with the ordinary activities of daily living is not covered.

VISION CAREWhat Is CoveredThe Plan covers one routine eye examination per year. It can be obtained from a USFHP provider. This includes refractions. It also includes a written lens prescription. Members can self-refer to any participating TRICARE provider for routine annual eye exams. It is the member’s responsibility to confirm the provider’s acceptance of TRICARE reimbursement.

Medical Eye ExamsSuppose you have a condition and need eye exams more frequently. Your primary care provider may give you a referral to see an ophthalmologist. This is a medical doctor who specializes in eye care. Your PCP will determine when you should be referred to an ophthalmologist and when you should be seen by an optometrist.

What Is Not CoveredCorrective lenses, frames, contact lenses, and contact lens fittings are generally not covered.

OTHER SERVICESAmbulance ServiceThe Plan covers ambulance service for emergencies. It must be a life-threatening emergency. The transportation will go to the nearest facility for treatment. Other needs for transportation are based on TRICARE criteria and if it is medically needed. Copayments for each ambulance service are as follows: Retirees who are over age 65 and do not have Medicare Part B have a $20 copay. Active duty family members and retirees with Medicare Part B do not have a copay.

NOTE: Riding in an ambulance from the hospital to your home is not a covered benefit.


Diagnostic ServicesIf your primary care provider or specialist authorizes these services, you do not pay an extra copayment:

• Pathology/lab services• Nuclear medicine services• Cardiovascular studies• Radiology/ultrasound services

Suppose you see your PCP or a specialist on the same day as the above services. A copayment might be collected for the office visit. Retirees and their family members who do not carry Medicare Part B will have a copay. Active duty family members are not required to pay copays. Also, retirees with current Medicare Part B are not required to pay copays.

Durable Medical EquipmentDurable medical equipment (DME) may be covered. It must be deemed medically necessary by the Plan. It must be authorized by your primary care provider. It also must be purchased or rented from a Plan provider. Retirees and their family members who do not carry Medicare Part B will have a copayment for DME. Active duty family members do not have a copay for covered DME. Also, retirees with current Medicare Part B do not have a copay for covered DME.

Hospice CareHospice care is a program for people who are terminally ill. It provides an integrated set of services and supplies designed to care for them. This type of care emphasizes pallia-tive care and supportive services. Examples of these services are pain control and home care. Hospice service provides a humane and sensible approach to care during the last days of life.

NOTE: Eligibility is determined by primary care providers. It also may be determined by specialists. They use established medical standards to make the decision. They will refer patients to approved providers of hospice care.

IF YOU GET A BILLFor services covered and authorized by USFHP, there are no claim forms or bills (except for copayments). But if you happen to get a bill, we’ll help clear up the problem for you. If you ever receive a bill for covered services from your PCP or from a provider to whom your PCP referred you, just forward it to:


Alternatively, you may call Member Services at 1 (800) 585-5883.


MEMBER SERVICESIf you would like information on benefits and services, the Member Services depart-ment is here to help you. You also may contact us to offer a suggestion, lodge a com-plaint, or share a compliment. Member Services can assist you with USFHP benefits. We are also available to resolve member issues.

The Member Services department is available Monday through Friday. Our hours are 8:00 a.m. to 4:30 p.m. You may call or write to us:


1 (800) 585-5883

MEMBER RIGHTS AND RESPONSIBILITIESMember Rights

As a US Family Health Plan member, you have the right to:

• Get information about covered benefits and cost sharing.• Get information about US Family Health Plan and our services. Get facts about

our licensure, certification, and accreditation status.• Get information about our doctors, providers, and facilities. This includes learn-

ing about the makeup of our network.• Have a choice of healthcare providers. The choice should be good enough to

ensure access to the high-quality healthcare that you need.• Get data on the satisfaction of Plan members.• Know how to access specialists. Know how to access emergency services.• Get considerate and respectful care that aims to maintain your dignity at all

times.• Have access to all of the healthcare and treatment services we provide. This

includes data on our management of care. (Access depends on the availability of resources. It also must be within generally acceptable standards.)

• Have access to services for emergency healthcare when and where the need arises.

• Refuse treatments to the extent permitted by law and government regulations. You also have the right to be told the consequences of such refusal of treatment.

• Question whether the care being provided is adequate.• Have privacy and confidentiality with your medical care and records. You have

this right to the extent permitted by law. You have the right to approve or refuse the release of such information; you will be afforded the opportunity to do this. One exception is when release is required by law or the Department of Defense.


• Know the identity and professional status of the provider who is most respon-sible for handling your care. You have the same right with the other healthcare people who take part in your treatment.

• Take part in decisions about your healthcare. Members who cannot fully take part in such decisions have the right to have certain other people represent them. These people are parents, guardians, family members, or other conservators.

• Understand an explanation of the diagnosis and treatment of your illness. You also have the right to understand what the future of your illness may be.

• Be informed of key aspects of your treatment so that you can make informed decisions about your care. These aspects include possible complications, risks, and benefits if you consent to or refuse a treatment. You also have the right to know about alternative treatments.

• Be advised if US Family Health Plan intends to engage in or perform experimen-tal research. This will help you make informed decisions about your care. You have the right to refuse to participate in such research.

• Get care and treatment in a safe environment. You also have the right to be informed of the facility’s rules and regulations that relate to patient and visitor conduct.

• Be informed of the US Family Health Plan system for member complaints and appeals. This system is specifically for the initiation, review, and resolution of patient complaints and appeals.

• File complaints and appeals with US Family Health Plan. This is outlined in the Complaints and Grievances and Appeals Procedure sections of this handbook.

• Use our internal complaint and appeal processes. This is the way to address concerns that may arise.

• Get considerate, respectful care from all members of the healthcare system without bias. You cannot be discriminated against based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orienta-tion, genetic information, or source of payment.

• Report recommendations or questions you have to a Member Services Represen-tative. Doing so will help us better serve all members.

Member Responsibilities

As a US Family Health Plan member, you are responsible for:

• Being well-informed about your health plan coverage and health plan options. This includes all covered benefits, limitations, and exclusions. It also includes rules about the use of network providers and about coverage and referrals. It also includes the proper processes to get more information. Finally, it includes the process to appeal decisions about coverage.


• Providing your doctor with complete information about your health, to the best of your knowledge. This includes your past medical history and other related topics.

• Being involved in specific choices about your healthcare.• Complying with the medical and nursing treatment plan you have agreed on

with your provider(s). This includes follow-up care. It also includes keeping appointments and letting providers know, in a timely way, if you must miss one. You also are responsible for telling your provider if you do or do not understand the treatment plan and what is expected of you.

• Boosting healthy habits. Examples are exercising, not smoking, and eating a healthy diet.

• Making a good-faith effort to meet financial duties. This includes paying copay-ments at the time that services are received.

• Following the claims process. You are responsible for using the disputed claims process when you disagree with a claim.

• Being considerate of the rights of other patients. You are responsible for being considerate of US Family Health Plan staff and network providers.

• Having respect for the property of other people and facilities.• Following the rules and regulations about patient conduct at all provider facili-

ties. This includes rules about not smoking, about parking, and so on.• Reporting wrongdoing and suspected fraud. You should report it to the proper

resources or legal authorities.

COMPLAINTS AND GRIEVANCESIf a US Family Health Plan member has a complaint or grievance, it will be addressed. A complaint might be about personnel, quality of care, service, or Plan benefits. If you have a complaint, you should call Member Services at 1 (800) 585-5883. US Family Health Plan staff will work to resolve your complaint so that you are satisfied.

You may also submit a formal grievance in writing to the Plan. This initiates the grievance process. Our address is:


All grievances will be resolved within 30 business days. If the Plan requires more time, you will receive a letter that explains the delay and when to expect the process to be completed.


APPEALS PROCEDUREIf you disagree with certain types of decisions made by US Family Health Plan, you can use the appeals procedure. For example, you may file an appeal because a claim was denied by the Plan.

There are two types of appeals: factual or medical necessity. A factual appeal asks the Plan to reconsider a claim or authorization that was denied because:

• The service was not a covered benefit under TRICARE.• The service was not preapproved by US Family Health Plan.

A medical necessity appeal asks the Plan to reconsider an authorization that was denied because:

• The member’s condition does not meet the standards of medical necessity.• The services go beyond what is considered to be medically necessary.

Appeals must be filed in writing and must meet specific timeframes. You may submit your appeal by mail, fax, or email. A Plan beneficiary may make an appeal on his or her own behalf or have a representative file the appeal for them.

Your appeal must be received by US Family Health Plan within the timeframe shown in the table below. The timeframes are based on the type of appeal and the date of the notice of the initial denial determination. The Plan will accept your appeal for review only if it is received on time.

Type of Appeal Filing Timeframes

Factual appealUSFHP must receive the appeal within 90 calendar days of the initial denial.

Medical necessity appeal: Concurrent (the member is an inpatient in a facility)

USFHP must receive the appeal by 12 noon of the day after the day of the initial denial.

NOTE: The member must be in the facility when the appeal is received.

Medical necessity appeal: Expedited (before the member is admitted to a facility or has a procedure)

USFHP must receive the appeal within 3 calendar days from the date the member received the denied authorization.

Medical necessity appeal: Not expedited (the member is an inpatient in a facility)

USFHP must receive the appeal within 90 calendar days of the initial denial.


Your appeal should include these items:

• The member’s name, address, and phone number• The sponsor’s name • The decision being appealed • All pertinent information about the issue • Copies of any related documents to support the appeal

All appeals must be submitted to the Plan in writing at the following address:

US Family Health PlanMember Services/Appeals1200 12th Avenue S, Qtrs 8/9Seattle, WA 98144

The Plan will send you a letter confirming that it has received your appeal. The letter also will state when you can expect a final decision of your appeal, following TRICARE guidelines.

The decision notice will explain the Plan’s reasons. It also will cite any sources or authorities for the decision. You will also learn about any further appeal rights and procedures, following TRICARE guidelines.

Please contact Member Services if you need assistance with filing an appeal: 1 (800) 585-5883.

For additional reference on the appeals process, please see the TRICARE operations manual: 6010.56-M, February 1, 2008, Chapter 12.

CONFIDENTIALITYMedical and other information that members give to the Plan will be kept confidential. It will be used by Plan providers and administrators for:

• Coordination of care• Claims adjudication• Program integrity• Investigation of fraud or abuse• Quality assurance• Responding to inquiries from congressional offices• Peer review• Coordination of benefits with other plans• Subrogation of claims• Review of a disputed claim


DEFINITION OF TERMSAccidentAn event causing external or internal trauma to the body. The event is sudden and unexpected.

Alcoholism or Drug Addiction Treatment FacilityA place that treats people who are addicted to alcohol or drugs. Services are provided in an inpatient setting.

Applied Behavioral AnalysisAn approach to changing how a person behaves in response to what’s going on around them. Steps include observing a behavior, and assessing what is driving it and the response it gets.

Attending PhysicianThe physician who is primarily responsible for your care. Care is delivered in an inpa-tient hospital setting.

Authorized ServicesThose services authorized by the Plan to be given to you. The services must be recom-mended by your primary care provider (PCP).

Catastrophic CapA cost “cap” or an upper limit on out-of-pocket costs. The cap is placed on USFHP covered medical bills. The cap for an active duty family is $1,000 per enrollment year. Retiree families have a catastrophic cap of $3,000 per enrollment year.

Contractor(s)Refers to a USFHP program or a Managed Care Support Contractor.

CopaymentThe fee you are required to pay for some services.

Covered ServicesFirst, those healthcare services specified in:

• DoD Regulation 6010.8-R, “Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)”

• “DoD Regulation 6010.47M” (the manual that accompanies the above)

In addition, the preventive services specified in:

• “A Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force” (Williams & Wilkins, 1996)


Custodial CareServices and supplies that are given to an individual mostly to assist in the activities of daily living. These items include room and board and other institutional services. The person may or may not be disabled. Custodial care is not a covered benefit under USFHP.

Defense Enrollment Eligibility Reporting System (DEERS)The data bank that lists all active and retired military members. It also lists their family members. The data bank is nationwide and computerized. Active and retired service members are listed automatically. They must submit their dependents themselves. They also must report any changes to family members’ status. (Status changes may happen with divorce, adoption, and so forth.)

DependentThe spouse, eligible child, or adult-age, disabled child of a sponsor. They may be deemed to be entitled to military benefits. This is determined by military rules.

Designated Provider of TRICARE PrimeA public or nonprofit entity that was a transferee of a Public Health Service hospital and designated by public law to provide the TRICARE Prime Uniformed Benefit. USFHP at Pacific Medical Centers is a Designated Provider of TRICARE Prime. There are six designated providers in the United States.

Durable Medical EquipmentMedical equipment such as wheelchairs, hospital beds, and oxygen. It is covered when medically necessary.

Eligible PersonA Military Health System beneficiary who meets the requirements set forth in the Eligibility section of this Handbook.

EmergencyThe sudden and unexpected onset of conditions that require attention right away. Such an event may endanger life, a limb, or sight.

Enrollee or MemberA uniformed services beneficiary who seeks and is accepted for enrollment in USFHP. He or she chooses the Plan voluntarily. This is his or her chosen way to get the health-care services that are spelled out in the selected enrollment option from the Military Health System (MHS). Eligibility for enrollment is based on two things. First, the per-son must be eligible to receive care in the MHS. Second, the person must be a resident within a USFHP service area.

Extended Care Health Option (ECHO)A program for beneficiaries who have special needs. It provides financial assistance and gives them access to an integrated set of services and supplies.


Family MemberThe spouse or child of an active duty or retired uniformed sponsor.

Home HealthThe Plan provides home care when it is necessary for medical reasons and the patient is homebound. The care may include durable medical equipment. Home care includes intermittent visits for physical, speech, nursing, or occupational therapy at home. These are provided only for short, defined periods.

HospitalAn institution that 1) provides medical care and treatment of sick and injured persons on an inpatient basis; 2) has the proper licenses or legal permits to operate as such; 3) has a physician on call at all times; 4) has licensed graduate registered nurses on duty at all hours; 5) has facilities to diagnose and treat illness and for major surgery; and 6) meets the required standards of the Joint Commission on Accreditation of Healthcare Organizations.

The definition of hospital may also include 1) facility that treats alcohol or drug addic-tion; 2) psychiatric hospital; 3) outpatient surgical facility; and 4) freestanding birth center. The facility must be licensed in the state in which it operates; it must operate within the scope of its license. In no event will the definition include a facility or any part of one that is a convalescent or extended-care facility. It also will not include any institution that is used primarily as 1) a rest facility; 2) a nursing facility; 3) a facility for the aged; or 4) a place for custodial care.

IllnessAny sickness or disease that shows symptoms and needs to be treated by a licensed provider. The sickness or disease is physical or mental. This includes pregnancy (for the purpose of defining coverage).

InjuryAny accidental bodily damage or hurt. It must be sustained while a person is covered under the Plan. It must require treatment by a physician.

InpatientA person treated in a hospital as a registered bed patient. It must be upon the recom-mendation of a physician.

Managed Care Support Contractor (MCSC)The contractor designated by the DoD to operate TRICARE in a particular region. The contractor is civilian. The contractor works with the MTFs.


Medically NecessaryMedically necessary care is the service or supplies provided by a hospital, physician, or other provider for the prevention, diagnosis, or treatment of an illness, when those services or supplies are determined to be:

1. Consistent with the condition, illness, or injury of the patient.2. Provided in accordance with the approved and generally accepted medical or

surgical practice. That practice must prevail where and when the service or supply is ordered.

3. Delivered in the most appropriate healthcare setting.

Military Health System (MHS)The system for military healthcare benefits. Patients of the MHS include eligible mem-bers of the uniformed services and retirees. It also includes their family members.

Military Treatment Facility (MTF)A military hospital, clinic, or other facility. Its purpose is to furnish medical care to eligible individuals.

OutpatientA covered person treated on a basis other than as inpatient. He or she is treated in a hospital or other covered facility.

PhysicianA legally qualified person who acts within the scope of his or her license. He or she holds the degree of Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.).

PlanThe US Family Health Plan as presented in the formal Plan document.

Plan ProviderAll professional providers and facilities associated with US Family Health Plan. A Plan provider’s purpose is to render care to enrollees in the Plan. The care must be covered and authorized.

Plan YearThe Plan year is from Oct. 1 through Sept. 30.

Primary Care Provider (PCP)A provider dedicated to the individual patient, providing most of his or her care. The PCP refers the patient to specialty care when needed. Each USFHP member has a PCP. The PCP knows the member’s medical history, monitors specialist care or tests, and helps the member prevent medical problems in the future. At USFHP, PCPs specialize in internal medicine, family medicine, family practice, or pediatrics.


ProviderA healthcare professional; also, an institution, facility, or agency. It must be licensed by the appropriate authority. It must operate according to law. A provider can be a hospi-tal, physician, doctor of podiatry (D.P.M.), and licensed clinical psychologist (Ph.D.). It also can be a certified nurse practitioner, physician’s assistant, and certified nurse midwife. A behavioral health counselor is also a provider.

ReferralA formal, written recommendation from a provider that directs a patient to receive services. The right to such services shall not exceed the limits of the referral. The right also is subject to all terms and conditions of the group contract. The services must be authorized by the Plan in order to receive optimal benefits.

Room and BoardCharges made by a hospital or other covered institution for the cost of the room and general duty nursing care. It also includes other services routinely provided with all inpatient care.

Semi-Private ChargeThe charge made by a hospital for a room containing two (2) or more beds.

Service AreaThe geographic area in which USFHP makes covered services available to enrollees. The area is defined by ZIP codes. This area is approved by the Department of Defense.

Skilled Nursing Facility (SNF)These are places of residence for people who must have constant skilled nursing care. They are unable to do a significant amount of the activities of daily living. Adults 18 or older who have had an accident or illness may stay in an SNF to get special therapy. They may get physical, occupational, and other rehabilitative therapy. SNF visits are covered when provided by an authorized provider for the diagnosis or treatment of a specific illness or condition or set of symptoms.

Split EnrollmentRefers to multiple members of a family enrolled in TRICARE Prime but under different Lead Agents or contractors. This includes Managed Care Support Contractors. It also includes USFHP designated providers.

SponsorA person who gives eligibility for benefits under TRICARE/USFHP. He or she must be an active duty or retired military person.

TRICARE PrimeThe benefit that provides the most comprehensive coverage for healthcare benefits at the lowest cost. Each member has a primary care physician who manages all the member’s healthcare. TRICARE Prime is the same plan type as USFHP.


TRICARE SelectThe name for a healthcare option under TRICARE. Under this option, beneficiaries may choose any physician they want for healthcare and pay either a fixed amount or a percentage of the cost.

Urgent CareHealthcare services that are required within several hours. In all cases, care is needed after the start of an illness or accidental injury. The illness or injury is not life-threat-ening. Examples of urgent care situations include a sprained ankle or a cut that needs stitches.

US Family Health Plan Member CardThe card issued by the Plan, identifying a military beneficiary as a member of the Plan. It includes important copayment and compliance information. It should be kept with you at all times.


US Family Health Plan1200 12th Avenue S, Qtrs 8/9Seattle, WA 981441 (800) 585-5883 www.usfhpnw.org

TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.

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Documents

Member Handbook - usfhpnw.org