USFHP News 2020 Issue 1

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

Your US Family Health Plan is an HMO-type plan that includes two different benefit levels: The In-Network benefit level and the Point-of-Service benefit level. It’s very important to understand, in advance, the difference between these benefit levels to avoid unexpected costs.

  • In-Network: Members generally receive health care from one of the Plan’s 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 at no or very low costs to members with no deductibles.
  • Point-of-Service: This benefit allows members the flexibility to choose to see an out-of-network provider when the service is available from an in-network provider, but at higher member costs (see details below). 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.

Point-of-Service Member Costs: When you use the Point-of-Service option to get care outside of the US Family Health Plan network, you will pay a deductible of $300 per year for an individual or $600 per year for a family for outpatient services. Once your deductible is met, you will have a cost share for inpatient and outpatient services of 50% of the TRICARE Maximum-Allowable Charge (TMAC). In addition, you may be subject to “balance billing” if you receive services from a provider who does not participate with TRICARE. You will be responsible for paying these bills, which may be amounts up to 115% of the TMAC. Any amounts paid for services received through the Point-of-Service benefit are NOT applied to your “catastrophic cap,” which means there is no maximum limit to these charges. If the provider you want to see does not participate with Medicare or TRICARE, you might be responsible for the entire bill.

(Note: When services are not available from an in-network provider and you are referred out of network, the referring provider may request an authorization for services to be covered at the in-network benefit level.)

The Point-of-Service benefit does not apply to:

  • Care received by newborns and adopted children during the first 90 days after birth or adoption
  • Emergency care
  • Radiology
  • Pathology
  • Anesthesiology, while inpatient
  • If you have other health insurance
  • Care being sought is not a TRICARE benefit or is determined not to be medically necessary

Additionally, Zostavax® vaccine, non-emergent ambulance, diagnostic services, dialysis, diagnostic drugs, and sleep studies are not subject to the Point-of-Service benefit level.

NOTE: This is not a comprehensive list; depending on billing, there may be other services that may or may not be covered under your POS benefit. Please visit here to learn more about your Point-of-Service benefit.

Some Durable Medical Equipment (DME) requires preauthorization by the US Family Health Plan, and not all durable medical equipment is covered under the Plan. Make sure to use an in-network vendor for your DME supplies.

For the lowest out-of-pocket cost, you can find in-network providers on our online provider directory.

Please call Member Services at 1-888-674-8734 to discuss questions you may have about the Point-of-Service option.

Breast Cancer Awareness Month is March!

Did you know about one in eight (about 12%) of women in the US will develop invasive breast cancer over the course of her lifetime?
In 2020, an estimated 268,600 new cases of invasive breast cancer are expected to be diagnosed in women in the US, along with 62,930 new cases of non-invasive (in situ) breast cancer. Breast cancer screening cannot prevent cancer, it can help find breast cancer early, when it is easier to treat.
For more information, visit the American Cancer Society or Centers for Disease Control and Prevention websites: cancer.org and cdc.gov/cancer/breast.

2020 Benefit Changes for Routine 3D Mammograms

Effective January 1, 2020, please see the following guide to coverage:

For women 40 and above: You have coverage for routine 3D mammogram screenings (instead of the conventional two-dimensional screening mammography) at no cost. Authorization is not required.

For women aged 30-39 who are considered high risk per TRICARE requirements: You will be allowed a 3D mammogram annually at no cost. You should discuss with your doctor to find out if you meet criteria. Authorization is required to determine if high-risk criteria is met and your provider can submit this request for you. If you meet the criteria for coverage, you are allowed to receive your 3D mammogram annually (with a 30-day grace period) at no cost at any facility that accepts both Medicare and TRICARE.

For women aged 29 or younger: 3D mammograms are not covered as an annual benefit.

2020 Enrollment Fee and Copay Changes

Effective January 1, 2020, the Department of Defense increased plan premiums and certain individual benefit copays for all TRICARE Prime® plans including the Martin’s Point US Family Health Plan. Those changes are as follows:

FOR MILITARY RETIREES ONLY

Please note active-duty family members or enrolled plan members who have Medicare Parts A & B do not have enrollment fees or copays for in-network covered benefits.

Plan Enrollment Fees (as of January 1, 2020)

  • Group A (Sponsor’s initial enlistment or appointment occurred before January 1, 2018) $300/year for individuals or $600/year for families
  • Group B (Sponsor’s initial enlistment or appointment occurred on or after January 1, 2018) $366/year for individuals or $732/year for families

Plan Copay Changes (As of January 1, 2020)

  • Specialty Office Visits referred by your PCP: $31 per visit (Increased from $30)
  • Urgent Care: $31 per visit (Increased from $30)
  • Emergency Room Visits: $62 per visit (waived if admitted) (Increased from $61)
  • Inpatient (Hospitalization): $156 per admission (Increased from $154)
  • Ambulatory Surgery: $62 per procedure (Increased from $61)
  • Skilled Nursing Facility Care: $31 per day (Increased from $30)
  • Maternity Services: $156 per admission, no separate copayment for separately billed professional charges (Increased from $154)
  • Mental Health Services: Outpatient Individual/Outpatient Group $31 per visit (Increased from $30)
  • Mental Illness and Substance Abuse Treatment Inpatient (must be preauthorized and is subject to annual limitations): $156 per admission, no separate copayment for separately billed professional charges (Increased from $154)

FOR ACTIVE-DUTY FAMILY MEMBERS AND MILITARY RETIREES*

*Pharmacy copays changed for all (except medically retired or survivors)

2020 Prescription Drug Copays (formulary generic/formulary brand-name/nonformulary)

  • Retail (up to 30-day supply): $13/$33/$60 (Increased from $11/$28/$53)
  • Mail-Order (up to 90-day supply): $10/$29/$60 (Increased from $7/$24/$53)

The Five Ws of Statin Therapy

WHAT ARE STATIN MEDICATIONS?

Statins are medications that help lower cholesterol for patients with high cholesterol. They have been an important part of the therapy for treating LDL (bad) cholesterol for many years. They also benefit people at risk for cardiovascular disease by reducing their risk of heart attack or stroke. Statins available in the US include:

  • Atorvastatin (Lipitor®)
  • Fluvastatin (Lescol®)
  • Lovastatin (Mevacor®, Altoprev®)
  • Pravastatin (Pravachol®)
  • Rosuvastatin (Crestor®)
  • Simvastatin (Zocor®)

WHO SHOULD BE TAKING A STATIN?

You should be taking a statin if you:

  • Have high LDL (bad) cholesterol
  • Have cardiovascular disease
  • Have conditions that put you at a high risk for heart disease, including:
    • High blood pressure
    • Diabetes
    • Obesity
    • Metabolic syndrome
    • Chronic inflammatory disorder and HIV

WHY SHOULD YOU TAKE A STATIN?

Statins reduce the amount of cholesterol in the blood. Statins are most effective at lowering LDL (bad) cholesterol. They also help lower triglycerides (blood fats) and raise HDL (good) cholesterol. Lowering LDL levels by 1% generally equals a 1% reduction in heart disease and stroke, but reductions can be higher depending on starting levels of cholesterol.

WHEN SHOULD YOU TAKE YOUR STATIN MEDICATION?

It is very important to take your statin medications as prescribed to make sure you get the greatest benefit. It’s better to take some statins at bedtime, as your body makes cholesterol while you sleep. Like all medications, you can experience side effects with statins. A rare, but well-known, side effect is muscle pain. If you experience muscle pain while taking a statin, taking your dose every other day may help. Be sure to talk to your doctor or pharmacist about which statin is best for you, and how you should take it.

WHERE CAN YOU GET MORE INFORMATION ON STATINS?

For more information, visit the American Heart Association or Centers for Disease Control and Prevention websites: https://www.heart.org or https://www.cdc.gov.

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