US Family Health Plan eNews Issue 4 2019


Get Your Flu Shot EVERY YEAR!

If you’ve already gotten your flu shot this season, thank you for taking care of yourself. If you haven’t, please consider getting this important vaccination as soon as possible. The flu strains that make up the vaccine change every flu season, so it’s important to get a shot each year.

Nearly everyone aged six months or older, including pregnant women, should be vaccinated. Some people should not get a flu shot, including some people with a history of Guillain-Barré Syndrome, some people with compromised immune systems, those who are allergic to eggs or to flu vaccine or any ingredient in the vaccine, and infants under six months old. If you are not feeling well, it is recommended that you postpone getting the flu shot until you are feeling better.

For information on the flu shot, please CLICK HERE.  For information on how the flu shot is covered under your US Family Health Plan, please call Member Services.

Sore throat? Antibiotics aren’t always the right treatment!

With sore throats, the cause will determine the treatment.

Most sore throats are caused by viruses and will go away in one to two weeks on their own, without an antibiotic. Antibiotic treatment in these cases may actually cause harm to your child. Some sore throats are caused by bacteria. In children, only 20 to 30 percent of sore throats are caused by Group A streptococcus bacterium (strep throat). 

You should consult a doctor if your child’s sore throat lasts longer than a week, if they have difficulty swallowing or breathing, and/or have drooling, rash, and joint pain.

Is my child’s sore throat caused by a virus or by bacteria?

It can be hard for a doctor to tell the difference between a viral sore throat and a bacterial strep throat based only on a physical exam and symptoms. It is important for your doctor to know if your child’s sore throat is caused by a virus or streptococcus bacteria. They may swab your child’s throat for a rapid strep test (if available in the doctor’s office). If the rapid test is positive, they may immediately prescribe an antibiotic to help prevent the complications associated with these bacteria. If it is negative, part of the swab will be kept for culture. Within two to three days, it will show if the strep bacteria are present and then treatment will be determined.

If your child’s sore throat is viral, treatment will focus on their comfort as there is no benefit and may be harm in using antibiotics. The doctor may recommend rest, acetaminophen (for pain), increased fluids, and throat lozenges.


Treating Your Kid’s Common Cold?

Antibiotics don’t work on these pesky viruses!

More than 200 viruses can cause the common cold and they can spread easily through the air and close personal contact. With kids back in school, it won’t be long before they start coming home with stuffy noses, sneezing, coughing, ear or sinus pain, and fever.

When your child is suffering from upper respiratory infection (URI) symptoms (also known as the common cold), it's natural to want to help them feel better as quickly as possible. For many parents, that means asking the doctor to prescribe an antibiotic for their child.

Unfortunately, most colds are caused by viruses, which antibiotics are not effective in treating. In fact, treating a viral infection with antibiotics can actually cause harm to your child. Instead of antibiotics, your doctor is likely to suggest rest and fluids along with over-the-counter pain killers and decongestants to help reduce symptoms and help your child feel better.

If your child’s cold lasts more than 10 days without improvement or they have symptoms that are severe or unusual, you should consult a doctor. The doctor will do a physical exam and, if they feel it necessary, they may swab the inside of your child’s nose or mouth to help determine what type of illness your child has and determine if any different treatment is needed.



Back Pain? For Most, Imaging Tests Don’t Help!

If you're like many people with back pain, you may think you need an imaging test (X-ray, CT scan, or MRI) to find out what is causing your pain. But these tests often don't help you feel better faster and they come with risks.

Research shows that most people with lower-back pain feel better in about a month, whether or not they have an imaging test.

Imaging tests can be expensive, expose you to radiation, and can lead to unnecessary surgery and other treatments. In one study, people who had an MRI were much more likely to have surgery than people who didn't have an MRI. But the surgery did not help them get better any faster.

When are imaging tests a good idea?

In some cases, you may need an imaging test right away. Talk to your doctor if you have back pain with any of the following symptoms, as they can be signs of nerve damage or a serious problem such as cancer or an infection in the spine:

  • Weight loss that you cannot explain
  • Fever over 102° F
  • Loss of control of your bowel or bladder
  • Loss of feeling or strength in your legs
  • Problems with your reflexes
  • A history of cancer

If you don't have any of these symptoms, it is recommended to wait a few weeks. Research strongly supports conservative treatment such as physical therapy and acupuncture to treat back pain, as opposed to the high-tech approach. If one approach does not work, try a different one.

This article is not a substitute for medical advice and treatment.



Point-of-Service Benefits: Know Before You Go!

Avoid unexpected high costs for out-of-network care under the Point-of-Service benefit.

Your US Family Health Plan is an HMO-type plan. This means that it is a managed care plan with participating contracted health care providers and medical facilities that may provide care. This type of plan includes two different benefit levels—the In-Network benefit level and the Point-of-Service benefit level.

  • In-Network: Members generally receive health care from one of our contracted network providers—the doctors, health care providers, hospitals, and durable medical equipment (DME) vendors who have agreed to take care of our members at negotiated rates. This care is provided with no deductibles and at no or very low costs to members.
  • Point-of-Service: This benefit allows members the flexibility to use out-of-network providers for medically necessary services that are also available from an in-network provider. Under the Point-of-Service benefit you must first pay a deductible and then you will have higher cost shares. While this benefit can give you greater freedom, you should be sure you understand what your out-of-pocket costs will be before you use this option.
  • When you are referred by your PCP to an out-of-network provider because it is believed that services are not available from an in-network provider, the referring provider may request an authorization for services to be covered at the in-network benefit level. During the authorization process, the plan will review medical criteria and policies to determine which benefit level is appropriate. If it is determined that the referred services are, in fact, available from an in-network provider, your authorization request to see an out-of-network provider may be approved, but it will be at the Point-Of-Service (more costly) benefit level.

BEFORE you use the Point-of-Service option to get care from a provider who is outside of the US Family Health Plan network, you should be aware of the following member costs: 

  • DEDUCTIBLE: You will pay a deductible of $300 per year for an individual or $600 per year for a family for outpatient services. 
  • COST SHARE: You will pay a cost share for inpatient and outpatient services of 50% of the TRICARE allowable charge. 
  • BALANCE BILLING: In addition, you may be subject to "balance billing" by the provider. Balance billing is when the provider bills you for an amount which is above the plan’s allowable rate, and what they may have billed the plan. 
  • NO MAXIMUM: Any services received through the Point-of-Service benefit is NOT applied to your "catastrophic cap," which means there is no maximum limit to these charges. 

ENTIRE COST: If the provider you want to see does not participate with Medicare or TRICARE®, you might be responsible for the entire bill. For the lowest out-of-pocket cost, you can find in-network providers on our online provider directory.

If you are considering receiving out-of-network services or have questions about the Point-of-Service option, we strongly recommend that you call Member Services at 1-888-674-8734.