1-800-678-7347 • www.USFamilyHealthPlan.org

Transcription

QUICK REFERENCE GUIDE
HAVE A QUICK QUESTION ABOUT THE PLAN?
Important Phone Numbers:
Emergency................................................DIAL 911
Then call us at 1-800-678-7347 within 24 hours.
24-Hour Nurse Line................................1-800-455-9355
Your Local Patient Advocates:
Bay Area Office:
CHRISTUS St. John.....................................281-336-3737
1-800-431-2666
Houston Office:
CHRISTUS St. Catherine &
St. Joseph Medical Center............................713-756-5933
Port Arthur Office:
CHRISTUS St. Mary.....................................409-989-5618
Behavioral Health Information:...............1-800-406-0022
Claims Information:...................................1-800-678-7347
Defense Enrollment Eligibility
Reporting System (DEERS)......................1-800-538-9552
US Family Health Plan Website:
www.USFamilyHealthPlan.org
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Pharmacy Information:
Your local CVS pharmacy
(for first-fills only on prescriptions):..............................1-888-607-4287
Mail-order pharmacy
Maxor Pharmacy........................................................1-866-408-2459
P.O. Box 32050 • Amarillo, TX 79120
Clear Lake Area
Maxor Pharmacy........................................................281-480-0327
1046 B Hercules • Houston, TX 77058
Cypress Area
Randalls pharmacy (this location only)...........................281-373-2507
12312 Barker Cypress Rd. • Cypress, TX 77429
Downtown Houston Area
Maxor Pharmacy..................................................................713-759-9040
1919 La Branch, George W. Strake Building,
2nd Floor • Houston, TX 77002
Galveston Island Residents (only)
CVS pharmacy.......................................................................409-740-0276
2326 61st St. • Galveston, TX 77551
CVS pharmacy.......................................................................409-763-3444
2425 Avenue J • Galveston, TX 77550
Jasper Area
Walmart (this location only)...............................................409-384-1707
800 W. Gibson St. • Jasper, TX 75951
Katy Area
Katy Pharmacy.......................................................................281-578-1515
20005 Katy Freeway • Katy, TX 77450
Lake Charles Area
CVS pharmacy.......................................................................337-855-1341
366 Sam Houston Jones Pkwy • Lake Charles, LA 70611
CVS pharmacy.......................................................................337-439-4241
2000 Ryan St. • Lake Charles, LA 70601
CVS pharmacy.......................................................................337-477-9068
4828 Nelson Rd. • Lake Charles, LA 70605
CVS pharmacy.......................................................................337-625-2660
1508 South Beglis Parkway • Sulphur, LA 70663
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Southeast Texas Area
Market Basket.......................................................................409-892-3226
(for first-fills only on prescriptions)
3955 Phelan Boulevard • Beaumont, TX 77706
Maxor Pharmacy............................................................409-989-5643
3701 Hwy. 73 • Port Arthur, TX 77642
Sugar Land Area
Ed’s Pharmacy......................................................................281-499-4555
3740 Cartwright • Missouri City, TX 77459
Willowbrook Area
Inwood Pharmacy...............................................................281-664-8829
13300 Hargrave Rd., Ste. 180 • Houston, TX 77070
Your US Family Health Plan Primary Care Physician:
(write your PCP’s information here)
Sponsor:
PCP’s Name:
PCP’s Phone Number:
Dependent:
PCP’s Name:
PCP’s Phone Number:
HOW TO GET THE CARE YOU NEED:
Show your US Family Health Plan member ID card at all
appointments, emergency room or other facility visits.
Show your member ID card before beginning any relationship
with a health care provider.
Emergency Care:
1) In a medical emergency, dial 911 or go to the nearest emergency
room or medical facility – even if it is not a US Family Health Plan
facility. Emergency care is covered worldwide.
2) Notify your PCP or The Plan within 24 hours of receiving
emergency care. The phone number for The Plan is on your
member ID card.
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NOTE:
A medical emergency requires immediate attention to prevent the
loss of life, limb or sight. (Examples of medical emergencies: heart
attack, stroke, poisoning, loss of consciousness, convulsions, etc.)
Urgent Care:
Examples of urgent care situations include a broken bone or
a cut that needs stitches. Call your PCP for instructions or an
approval for care.
If you are outside the 48 contiguous United States, urgent care
is covered without authorization from your PCP. Be sure to call
your PCP or The Plan as soon as possible (within 24 hours).
Routine and Preventive Care:
Examples of routine care include annual checkups, flu, fevers,
sore throats, etc.
There is no out-of-area coverage for routine or preventive medical
care. Your PCP must provide care or the referral for medical
services to be covered.
YOUR PRIMARY CARE PHYSICIAN (PCP):
The relationship you have with your doctor is most important.
When you enrolled, you chose a PCP. This doctor and staff will
take care of your health care needs including:
Referrals to specialists
Arrange for hospital admissions
Authorize urgent care, lab work, x-rays
or other medically necessary services
Handle all of the paperwork for The Plan,
so you don’t have to file claim forms
It is important that you feel comfortable with your physician choice.
In order to get the best care possible, discuss concerns or questions
about your care with your PCP. Our physicians have been through
an extensive credentialing process. They are committed to providing
excellent care and patient satisfaction.
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You can change your PCP as often as every 30 days, although we do
not recommend it.
If you are hospitalized at a network facility, you may be cared for by a
“hospitalist.” This doctor is a specialist in providing hospital care. The
hospitalist will coordinate your care with your surgeons, specialists and
PCP. This helps reduce delays for tests and gives you greater access to a
physician while in the hospital.
WHEN YOU NEED TO SEE A SPECIALIST
If you need to see a specialist, your PCP will arrange a referral. Your
PCP will work with The Plan to get approval on specialty referrals. This
assures that specialist costs will be covered by The Plan after you make
any necessary copayments.
WHEN YOU NEED A REFERRAL
You need a referral/authorization from your PCP for referrals to
specialists and medical services with few exceptions. The referral process
helps everyone because:
You and the specialist are sure that your PCP and The Plan
have authorized your care
The specialist knows why you were referred and has received
clear communication from your PCP
YOU DO NOT NEED A REFERRAL FOR THE
FOLLOWING SERVICES:
Annual well-woman exam. You can “refer yourself” to an
obstetrician/gynecologist, or you can see your PCP for this exam.
Eight visits to a US Family Health Plan Mental Health Provider
(see page 16 for more details and guidelines).
Emergency Care (see page 8 for more details).
Annual Eye Exam (see page 34 for more details). This service is
not a part of the TRICARE benefit. CHRISTUS Health provides
this added service for our plan members.
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COPAYMENTS:
Details on copays are provided on pages 16–18.
Pharmacy copayments:
TYPE OF
PHARMACY
NON-FORMULARY
DRUGS (Tier 3)
Generic
(Tier 1)
Brand Name
(Tier 2)
Mail-Order
Pharmacy (up to
a 90-day supply)
$0
$13
$43
Local Network
Pharmacy (up to
a 30-day supply)
$5
$17
$44
Non-Network
Pharmacy/
Point of Service
(POS) (up to a
30-day supply)
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FORMULARY
DRUGS
50% of total cost
applies after Point of
Service (POS)
deductible is met
50% of total cost
applies after Point
of Service (POS)
deductible is met
IMPORTANT NUMBERS
Member Services
Social Security Administration
1-800-678-7347
P.O. Box 169001
Irving, TX 75016
1-800-772-1213
for questions about enrollment, specific benefits
and coverage area
for information about how The Plan works
To verify US Family Health Plan
Coverage/Eligibility
1-800-678-7347
to change your primary care physician
Claims Information
to change your address and/or phone number
1-800-678-7347
to appeal decisions concerning covered benefits
to obtain a new membership card
to add a family member to The Plan
24-Hour Nurse Line
US Family Health Plan
Attn: Claims
P.O. Box 169001
Irving, TX 75016
1-800-455-9355
Member Resource Managers
Member Self Help/Wellness
Bay Area Office
281-336-3737 or 1-800-431-2666
Fax: 281-336-3725
Medline Plus® - http://medlineplus.gov
Health Information Library
1-800-455-9355
To notify The Plan of an Emergency
or Out-of-Area Care
1-800-678-7347
Meritain (Family Planning)
1-888-627-8889
P.O. Box 27083
Lansing, MI 48909-7083
APS (Behavioral Health)
1-800-305-3720
OTHER IMPORTANT NUMBERS
Medicare
1-800-633-4227
Office Address
2035 Space Park Drive, Suite 220
Houston, TX 77058
Mailing Address
18300 St. John Drive
Nassau Bay, TX 77058
Houston Area Office
713-756-5933
Fax: 713-756-5938
Office Address
1919 LaBranch, Suite 4400
Houston, TX 77002
Mailing Address
1401 St. Joseph Parkway
Houston, TX 77002
Port Arthur Area Office
409-989-5618
Fax: 409-989-5634
Mailing/Office Address
3701 Highway 73
Port Arthur, TX 77642
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IMPORTANT NUMBERS
Pharmacy Information
Your local CVS pharmacy
(for first-fills only on prescriptions):
1-888-607-4287
Mail-order pharmacy - Maxor Pharmacy
1-866-408-2459
P.O. Box 32050 • Amarillo, TX 79120
Clear Lake Area - Maxor Pharmacy
281-480-0327
1046 B Hercules • Houston, TX 77058
Cypress Area - Randalls pharmacy
(this location only)
281-373-2507
12312 Barker Cypress Rd. • Cypress, TX 77429
Downtown Houston Area - Maxor Pharmacy
713-759-9040
1919 La Branch, George W. Strake Building,
Galveston Island residents (only)
CVS pharmacy
409-740-0276
2326 61st St. • Galveston, TX 77551
CVS pharmacy
409-763-3444
Jasper Area - Walmart (this location only)
409-384-1707
Katy Area - Katy Pharmacy
281-578-1515
Lake Charles Area - CVS pharmacy
337-855-1341
366 Sam Houston Jones Pkwy
Lake Charles, LA 70611
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CVS pharmacy
337-439-4241
2000 Ryan St. • Lake Charles, LA 70601
CVS pharmacy
337-477-9068
4828 Nelson Rd. • Lake Charles, LA 70605
CVS pharmacy
337-625-2660
Southeast Texas Area - Market Basket
409-892-3226
(for first-fills only on prescriptions)
3955 Phelan Boulevard • Beaumont, TX 77706
Maxor Pharmacy
409-989-5643
3701 Hwy. 73 • Port Arthur, TX 77642
Sugar Land Area - Ed’s Pharmacy
281-499-4555
Willowbrook Area - Inwood Pharmacy
281-664-8829
13300 Hargrave Rd., Ste. 180 • Houston, TX 77070
Defense Enrollment Eligibility
Reporting System (DEERS)
1-800-538-9552
US Family Health Plan Website
Enrollment Fee Mailing Address (direct to bank)
P.O. Box 842045
Dallas, TX 75284-2045
TABLE OF CONTENTS
ABOUT THE PLAN.........................................................................................................................1
ENROLLMENT & ELIGIBILITY....................................................................................................2
RIGHTS & RESPONSIBILITIES..................................................................................................5
HOW YOUR CARE IS MANAGED..............................................................................................7
WHAT IS COVERED BY THE PLAN...........................................................................................10
OUT-OF-AREA COVERAGE..........................................................................................................15
SCHEDULE OF COPAYMENTS...................................................................................................16
WHAT IS NOT COVERED BY THE PLAN..................................................................................19
CLAIMS & BILLING INFORMATION........................................................................................ 22
GRIEVANCES & APPEALS..........................................................................................................23
COORDINATION OF BENEFITS................................................................................................. 24
IMPORTANT DOCUMENTS....................................................................................................... 25
FREQUENTLY ASKED QUESTIONS.......................................................................................... 27
ix
TABLE OF CONTENTS
PHARMACY BENEFITS................................................................................................................29
BEHAVIORAL HEALTH BENEFITS..............................................................................................33
OUR ENHANCEMENT PROGRAM.............................................................................................34
MEDICARE USAGE....................................................................................................................... 37
OTHER INFORMATION.................................................................................................................38
LIST OF NETWORK HOSPITALS.................................................................................................39
FORMS.............................................................................................................................................40
GLOSSARY OF TERMS.................................................................................................................75
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CHAPTER 1:
ABOUT US FAMILY HEALTH PLAN (“THE PLAN”)
HOW THE PLAN WORKS
Members of The Plan receive all of the medical services of the
TRICARE Prime benefit. Preventive health care services are
included in this Plan. You will also get enhancements offered
by CHRISTUS Health that are not offered by TRICARE. These
include annual eye exams and discounts on dental care, glasses,
contacts and hearing aids.
All eligible Military Health System (MHS) beneficiaries, age 64
and under, can join The Plan but must enroll. You may not be
denied enrollment due to pre-existing conditions. All of your
care is provided by or coordinated through your primary care
physician (PCP).
WHO SPONSORS THE US FAMILY
HEALTH PLAN?
The Plan is a TRICARE Prime option in six areas
of the country. Eligible beneficiaries in Southeast
Texas and Southwest Louisiana have an extra choice
for their health care. The Plan is part of CHRISTUS
Health and funded by the Department of Defense
(DoD). We are a non-profit, private health care
organization – not a contracted insurance company.
The Plan, its employees, agents and assignees make
decisions based on the policies and procedures set
forth by the Department of Defense (DoD).
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CHAPTER 2:
ELIGIBILITY AND ENROLLMENT
WHO IS ELIGIBLE?
CHANGES AFFECTING ELIGIBILITY
To be eligible to be a member of The Plan, you must be a
current eligible beneficiary of the Military Health System
(MHS). You must be enrolled in DOES (Defense On-Line
Enrollment System).
Additions to Your Family
Newborns or adopted children must be enrolled in the DOES
system within 60 days of the date of birth or adoption. A new
application must be completed for the child and submitted
to The Plan.
US Family Health Plan is a health benefits plan for eligible
active duty family members, retirees, retiree family members
and retired reservists age 60+, of all seven uniformed services:
the Army, Navy, Marine Corps, Air Force, Coast Guard,
Public Health and NOAA. This includes unmarried children
between ages 21 and 26 who meet the TRICARE Young Adult
qualifications (see page 4).
HOW TO ENROLL IN US FAMILY
HEALTH PLAN
Enrolling in The Plan is easy. Just follow the steps below:
Complete an application.
Applications can be obtained from:
• Member Services by calling 1-800-678-7347
• US Family Health Plan website
• The TRICARE website tricare.osd.mil
Mail your completed, signed application
and applicable enrollment fees to:
Attn: Member Services
P.O. Box 169001
Irving, TX 75016
2
Changing Your Address and Phone Number
This is very important!
If you change your address, please notify The Plan immediately.
Please contact Member Services at 1-800-678-7347.
Medicare Usage
Medicare usage is limited while enrolled in US Family Health
Plan. See page 37 for more details.
You cannot be enrolled in this plan and a Medicare Advantage
Plan at the same time.
Military ID Card
You must keep your military ID card current to remain eligible
in DOES. You must be DOES eligible to retain your US Family
Health Plan eligibility. Call Member Services at 1-800-6787347 for a listing of places that can update your card. If a gap in
coverage occurs, you will be responsible for all charges incurred,
including prescriptions.
CHAPTER 2:
ENROLLMENT GUIDELINES AND FEES
Enrollment Period
Your enrollment is effective on the first day of the month
following receipt of your application (and any applicable fees),
if received by the 20th of the month.
If your application and any required fees are received on or
after the 20th of the month, then your enrollment effective date
will be the first day of the second month. You are required to
remain in the program for one year. See Disenrollment section
(pages 3–4) for exceptions. If you are in the hospital on the
date that your coverage is scheduled to begin, your coverage
begins on the day after your hospital discharge.
Enrollment Fees
The required enrollment fee will depend on your enrollment
effective date. Visit the TRICARE website at tricare.osd.mil for
the most current information regarding enrollment fees or call
The Plan’s Member Services Department at 1-800-678-7347.
Active Duty Family Members
No enrollment fee
Retirees Who Pay Medicare Part B
$0 (proof of Medicare Part B payment must be provided)
The enrollment fee can be paid in-full at the time of
enrollment, in four (4) quarterly installments or by monthly
allotment. Enrollment fees can be paid by check, cashier’s
check, money order, traveler’s check, monthly allotment, billed
to your VISA or MasterCard credit cards, or by electronic
funds transfer. If you pay quarterly installments, you will
receive a bill at least 30 days before your payment is due.
Payments are always due on the 1st of the month. If you
do not receive your bill, please call Member Services at
1-800-678-7347.
Failure to pay enrollment fees can result in
disenrollment and loss of eligibility to re-enroll in The
Plan or TRICARE Prime for 12 months. You will be
financially responsible for any health care received during
the 30-day grace period.
Enrollment fee payments should be mailed directly to:
P.O. Box 842045
Dallas, TX 75284-2045
If a member moves or disenrolls before the end
of the 12-month period, the enrollment fee is nonrefundable. (Retirees who have been called back to
active duty or members with Medicare Part B can
request a fee refund of the unused portion of the
enrollment fee.)
Split Enrollment
Members can enroll in The Plan individually. If
you have questions about split enrollment contact
Member Services at 1-800-678-7347.
Portability
Portability allows you to continue your military health
care coverage during a permanent or temporary move
to another US Family Health Plan or TRICARE Prime
region. This benefit provides a seamless transition
of health care coverage from one region to another.
Notify Member Services before you move so that
effective coverage can be obtained in your new
area. You will not pay more than the standard
enrollment fee.
Should You Need to Disenroll
You are required to remain enrolled in The Plan for
twelve (12) months. If you disenroll from The Plan or
become ineligible due to:
A permanent move out of The Plan service area
A determination that you provided false
information to The Plan or committed fraud
Modification of The Plan
Amendment or termination of The Plan
Expiration of military identification
Loss of eligibility
3
CHAPTER 2:
Termination of sponsor coverage, except in the case
of the death of a sponsor (eligibility is determined by
the sponsor’s branch of service)
A marriage, birthday or other event that causes a
dependent to no longer be eligible for coverage,
according to the eligibility information in this booklet
Coverage for you and your family ends usually at
midnight on the last day of the month in which an event
occurs or as determined by the Department of Defense
(DoD) through the DOES system.
For those members over age 65, if you disenroll from
The Plan after September 30, 2012, you will not be
allowed to re-enroll.
As of September 30, 2012, military retirees 65 years or
older will not be able to enroll in any TRICARE Prime
option, including US Family Health Plan. Anyone joining
USFHP after September 30, 2012 will be disenrolled from
The Plan upon reaching age 65.
TRICARE YOUNG ADULT (TYA)
TYA is premium-based TRICARE coverage available
for purchase by qualified young adult dependents under
age 25 who are no longer eligible for TRICARE at age 21
(age 23 if formally enrolled in a full-time course of study
approved by the Secretary of Defense and more than
50% dependent on the uniformed service sponsor for
financial support).
The young adult dependent qualifies to purchase TYA
coverage if the following criteria are met:
Would be a dependent but for exceeding the age limit
Is a dependent under the age of 26
Is not eligible for medical coverage from an eligible
employer-sponsored health plan from the young adult
dependent’s employer
Is not married
Is not otherwise eligible for care under Chapter 55, 10
USC or Chapter 58, 10 USC Section 1145(a), TAMP, and
Is not a member of the uniformed services
The young adult must complete the prescribed paper
application (or complete the online form and print
it for mailing) and submit it, along with at least the
initial payment of three months worth of premiums.
TYA Prime effective dates will be determined using
the 20th of the month rule.
For questions about the TYA program, call Member
Services at 1-800-678-7347.
CHOOSING A PRIMARY CARE PHYSICIAN
(PCP)
On your application, you must select your personal
physician from one of the primary care physicians (PCPs)
listed in The Plan’s physician directory.
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CHAPTER 3:
MEMBER RIGHTS AND RESPONSIBILITIES
ENROLLMENT GUIDELINES AND FEES
The Plan supports the President’s Advisory
Commission on Consumer Protection. The Plan
also supports the Health Care Industry’s Consumer
Bill of Rights and Responsibilities. This document is
available at www.hcqualitycommission.gov
The Plan declares the following rights and
responsibilities of our members.
As a member of The Plan, you have the right to:
Change your PCP once every 30 days.
AS A MEMBER OF THE PLAN, YOU HAVE
A RESPONSIBILITY TO:
Pay your enrollment fees on time.
Pay copayments required by The Plan.
Not use Medicare Part A or B and Medicaid for
services covered by The Plan.
Update your military ID card as needed.
Make sure that your DEERS/DOES file information
and status is correct and current.
Notify Member Services at 1-800-678-7347 of a:
Attend all member meetings.
• Change of address and/or phone number.
Use all additional programs offered by The Plan.
• Change in eligibility for you or a family member.
Submit a letter if a problem concerning your health care
was not solved where it occurred. You can also talk with a patient advocate or Member Services representative about the problem.
Call and speak with a nurse 24 hours a day by calling
1-800-455-9355.
Have one complete eye exam each year.
Have one annual physical each year.
Get current information about the doctors and hospitals
that participate in The Plan.
Help your doctor make decisions about your health care.
Know how to make appointments and get health care
from your PCP during and after office hours.
Know how to contact your PCP or their on-call support
24 hours a day, every day.
Disenroll from The Plan if you move outside of The
Plan’s service area.
Provide The Plan with information if you are a member
of other health insurance plans.
Bring your member card with you when visiting your
doctor, pharmacy or seeking medical treatment.
Give your correct information to the provider any time
a claim is filed. The needed information is:
• The correct spelling of your first and last name.
• Sponsor’s Social Security number.
• Your correct date of birth.
Provide a complete medical history to your physician.
This includes a list of all your medicines (prescription
and over-the-counter).
5
CHAPTER 3:
MEMBER RIGHTS AND RESPONSIBILITIES
Use your plan PCP, plan network specialist (with
referral), plan network hospital/facility and the
network pharmacy for routine care.
Do not use the Military Treatment Facility (MTF),
TRICARE or NMOP (National Mail-Order
Pharmacy) for routine care.
Notify your PCP if possible before:
• Seeking emergency medical treatment.
• Seeking care outside of the service area (except
when outside of the United States).
6
Notify The Plan at 1-800-678-7347 within 24 hours for:
• Emergency medical treatment.
• An accident requiring medical attention (motor
vehicle accident, workers compensation, etc.).
• Note: Please notify The Plan as soon as possible.
If you are unable to call immediately, please do so
within 24 hours.
Transfer your medical record if it is necessary.
CHAPTER 4:
HOW YOUR CARE IS MANAGED
Plan members choose one PCP to manage their health
care. Your PCP is your “medical manager.” If the member
needs treatment outside the PCP’s scope of care, the PCP
may refer the member to a specialist.
THE ADVANTAGES OF A PRIMARY CARE
PHYSICIAN
One office to call when you need care.
Your PCP has good working relationships with the
specialists and hospitals where he or she refers you.
Your PCP and their staff can help you find your way in
the complex world of health care.
One provider has a picture of your overall health status
and medical needs, and can coordinate your care.
CHOOSING A PRIMARY CARE PHYSICIAN
(PCP)
You must choose a primary care physician (PCP) to
manage your care on your enrollment form. You can
choose from the list of doctors provided by The Plan. We
will try to provide you with your first choice. If your first
choice is not available, you will be given the chance to
pick another PCP. If your PCP decides that you require
specialist care or hospitalization, your PCP will send a
request for approval to The Plan. Your doctor will let you
know if the request is approved. Any medical services you
receive which are not coordinated by your PCP will not be
covered under The Plan. There is an exception to this rule.
You may receive the following from a network provider
without a referral from your PCP:
WHEN CARE IS MANAGED BY YOUR PCP
Medical care is covered when managed by your PCP and
approved by The Plan. Inpatient hospital services are also
covered when coordinated by your PCP and approved
by The Plan. Please refer to the “What is Covered by The
Plan” section of this booklet on page 10 for coverage
information. You can also call Member Services at 1-800678-7347. You are responsible for paying any copayments
that apply. For a list of copayments, please refer to pages
16–18.
You enjoy other benefits when your PCP manages your
medical needs. For example, you do not have to fill out
claim forms. Your PCP will take care of any approval
required by The Plan for medical services. The only
exception is when you are away from home or need
emergency services.
WHEN CARE IS NOT MANAGED BY
YOUR PCP
After your specialist referral has been approved, ongoing
care must be requested by the specialist.
Routine medical services that are not coordinated by your
PCP and/or not approved by The Plan will not be covered.
The only exception is a severe emergency.
A well-woman exam
Eight outpatient mental health visits
An annual eye exam
7
CHAPTER 4:
EMERGENCY CARE & URGENT CARE
Emergency Care
An emergency is defined as a medical, maternity or
psychiatric event that would lead a “prudent layperson”
to believe that a serious medical condition is happening.
Or, that the absence of medical attention would result in
a threat to his/her life, limb or sight and needs immediate
medical treatment. These emergency conditions would
reveal severely painful symptoms, requiring immediate
care to relieve suffering. This includes situations when a
member has severe pain.
Examples of medical emergencies include heart attacks,
strokes, severe bleeding, poisoning, loss of consciousness
or breathing, and seizures, which are often symptoms of
serious illness.
Note:
Normal obstetric delivery after the 34th week is not
considered an emergency. To obtain care during normal
labor after the 34th week, follow the directions provided
by your USFHP provider.
Emergency Room (ER) treatment that meets this
definition does not have to be approved by your PCP.
Members are urged to seek emergency care at the nearest
facility. You or someone else must call Member Services
within 24 hours after receiving that care. Please note: this
call is required by The Plan but is not an approval for
payment of emergency care services.
8
You should call your PCP before receiving emergency
care when possible. Emergency visit claims are reviewed
prior to payment. If it is determined the emergency room
care you received was not emergent, the care will not be
covered. The member is responsible for all costs for that
care. A copayment is required for each ER visit. If you are
admitted to the hospital, the inpatient copayment applies.
When you receive emergency care out of the area, present
your USFHP member ID card to the provider or hospital.
In some cases when you seek out-of-network care, you
may be asked to pay a deposit or pay for the services.
If this happens, please call Member Services at 1-800678-7347 for assistance.
Urgent Care
Urgent care is defined as health services for illnesses
or injuries that are not life threatening but require care
within 24 hours after the illness or injury occurs. The
Plan pays for urgent care when you are traveling outside
of the 48 contiguous states. The Plan pays for urgent care
when your PCP has authorized the care. Please see page
16 for copayment information.
Please tell the clinic or facility providing the care to send
the bill to The Plan. The Plan’s address is on your member
ID card. In some cases, when you seek out-of-network
care, you may be asked to pay a deposit or, in extreme
cases, required to pay for the service. If you are asked
to pay for medical care other than your copayment that
is covered by The Plan, please call Member Services at
1-800-678-7347 for assistance.
CHAPTER 4:
PLAN APPROVAL/MEDICAL MANAGEMENT
An important part of managed care is ensuring you
receive medically necessary, quality care. Plan approval
ensures that your care is received in the most appropriate
setting for your medical condition. Certain services such
as hospitalizations, diagnostic testing and outpatient care
require plan approval. For these services, your PCP or
treating provider must submit the request. These requests
are reviewed for medical necessity and plan coverage.
Medically necessary care is defined as the frequency,
extent and type of medical services or supplies that are
generally accepted by qualified professionals to be sound
and adequate to diagnosis and treat an illness, injury,
pregnancy or mental disorder. It also includes care that is
reasonable and adequate for well-baby care.
Services are reviewed for plan coverage and medical
necessity. Tools used for review are:
Generally accepted current medical care
The approved, generally accepted current local
area medical practice
Nationally accepted clinical guidelines
Not based on the convenience of the patient,
the doctor or other provider
Treatment for the member’s illness or symptoms that do
not exceed (in scope, duration or intensity) the level
of care needed to provide safe, adequate and appropriate
diagnosis and treatment
9
CHAPTER 5:
SERVICES & PROCEDURES
CARDIAC REHABILITATION
The Plan covers the same services you would receive
under TRICARE Prime. These services include
preventive care, such as annual physical exams.
Cardiac rehabilitation programs are covered when
patients have had any of the following during the
past 12 months:
Important Notice: A specific service
may be listed as covered. It will only
be covered if it is medically necessary
and approved by The Plan, if required.
Unapproved services may not be covered.
You may be responsible for the entire cost.
All services must be referred by your PCP (unless stated
otherwise). Many services require that you get plan
approval before you receive the service. Out-of-network
requests require plan approval and will be directed to
network providers if possible. Any copayments must be
paid at the time of service. See pages 16–18 for a full list
of copayments.
The Plan covers the following services:
10
WHAT IS COVERED BY THE PLAN
Heart attack
Open heart surgery
Coronary angioplasty (surgical reconstruction of
coronary blood vessels)
Percutaneous transluminal coronary angioplasty (use
of a balloon catheter inserted into a coronary blood
vessel to flatten plaque against the artery wall)
Chest pain – subject to certain limitations
Heart valve surgery
Heart transplants, to include heart-lung
Cataract Treatment
See Intraocular Lenses.
Chemical Dependency Treatment
See Mental Health Services in Chapter 15.
AIDS
The Plan covers FDA-approved AIDS medications and
treatments that are non-experimental.
Clinical Cancer Trials
See Chapter 18 for more information.
Alcoholism
See Mental Health Services in Chapter 15.
Computerized Tomography (CT) and
Magnetic Resonance Imaging (MRI)
Ambulance Services
Ambulance services are covered when medically
necessary, approved and when a member’s condition
does not allow use of private transport or taxis.
Examples include car accident, severe bleeding,
stroke, bed bound, etc.
Dental Care (For Treatment of an Injury or
Medical Condition)
Routine dental care is not covered. Eligible dental services
must be approved. Coverage limitations apply.
As an enhancement, The Plan offers discounts for routine
dental care. See Chapter 16 for more information.
CHAPTER 5:
Diabetic Education
Limitations apply.
Diabetic Shoes
Extra-depth shoes with inserts or custom-molded
shoes with inserts.
Diabetic Supplies
Contact Maxor Pharmacy at 1-866-408-2459 for a list of
approved glucose monitoring supplies.
Diagnostic Tests
No additional copayment is required if:
These tests are performed as a part of an office visit or
Part of clinical preventive services
Durable Medical Equipment (DME)
Rental and purchase options may apply for covered items.
ECHO (Extended Care Health Option)
Extended Care Health Option (ECHO) – ECHO is a
special benefit of the TRICARE Basic Program. ECHO
gives eligible active duty family members with qualifying
conditions an extra financial resource for services
and supplies.
Emergency Care
Eye Exam
Annual comprehensive eye exams are offered. Eye exams
related to medical treatment of an illness or injury are
covered and should be coordinated by your PCP.
Family Planning Services
Family planning services are covered. Services in
conflict with Catholic Directives cannot be provided by
CHRISTUS Health facilities or their associates. Meritain
Health and the Maxor Mail Order Pharmacy (see Chapter
14) provide family planning services. Covered family
planning services include:
Intrauterine device (IUD) insertion/removal/
replacement
Contraceptive diaphragm
Sterilization (including vasectomy and tubal ligation)
For more information, please call Meritain Health
at 1-888-627-8889.
Genetic Testing
Coverage limitations apply. Routine genetic testing that
does not influence the member’s medical management
is not covered.
Home Health Care
Services include:
Part-time skilled nursing care
Physical therapy
Speech therapy
Occupational therapy
Social services
Medical supplies
Home health aide services
(Coverage limitations apply.)
Hospice
Inpatient and outpatient hospice care is covered for
the terminally ill who are expected to live less than
six months. Coverage limitations apply. Non-hospice
pharmacy needs should be filled through the Maxor
Pharmacy and are subject to normal copay if any.
See Chapter 7 for more details.
11
CHAPTER 5:
Hospital Services – Inpatient
All inpatient services must be approved. Hospital services
may include:
Semiprivate room and board, private room only if
medically necessary
Doctor services related to medical treatment or surgery
Special care units, such as intensive care or coronary
care units
General nursing services
Diagnostic tests, including lab services and x-rays
Operating room, anesthesia and supplies
Medically necessary supplies and services
Prescribed inpatient drugs
Inpatient therapies (such as physical, occupational,
speech)
Services for TRICARE approved, non-experimental
human organ and tissue transplants if approved
Newborn care for children of unmarried members
for the first three days associated with the delivery
Limited coverage applies. For more information,
see Chapter 15.
Hospital Services – Outpatient
Some examples of outpatient services are outpatient
surgery, diagnostic tests or laboratory.
Hospitalist Services
At some network hospitals, care is managed by specialists
known as “hospitalists.” Their time is devoted to your
inpatient stay. They ensure you get the right care, at the
right time and in the right setting. Hospitalists may be
asked to follow your care if you are admitted for other
services (ex: surgical or obstetric). There is no out-ofpocket cost to you for these services.
12
Immunizations for Required Overseas Travel
Immunizations needed for active duty family members
whose sponsors are stationed overseas are covered.
Implants
Surgical implants are covered when they are approved by
the FDA. For example, breast implants after mastectomy.
Infertility Services
Infertility testing and treatment, including correcting
the physical cause of infertility, are covered. Services
may include testing, surgery, hormone therapy and
other procedures in overcoming the cause of infertility.
Coverage limitations apply.
Intraocular Lenses
Intraocular lenses implanted after cataract surgery
are covered. One set of either eyeglasses or contacts
is covered.
Maternity Services
Coverage includes care of the enrolled mother
and baby during pregnancy and delivery. There is no
copayment for prenatal visits or prescription prenatal
vitamins during this period. See Chapter 2: Enrollment
and Eligibility for more information.
Medical Supplies
Selected TRICARE approved medical supplies may
require plan approval. Copays may apply. Diapers and
blood pressure monitors are not covered.
Nutritional/Dietary Supplements
Must be main food source for covered conditions.
Limited coverage applies.
CHAPTER 5:
Obesity (Morbid) Treatment
Specific medical necessity criteria must be met for bariatric
surgery coverage. For example, body mass index (BMI)
results and a record of failed attempts at weight loss. PCP
referral is required. Limited coverage applies. Weight
control services, weight loss programs, exercise programs,
food supplements and weight loss drugs are not covered.
Organ Transplants
The Plan covers organ transplants such as:
Cornea
Kidney
Pharmacy Benefits
See Chapter 14 for complete details.
Physician Services
Office visits to your PCP or specialists (when referred
by your PCP).
Physical, Occupational or Speech Therapy
Inpatient and outpatient is covered to restore loss of
function is covered. General exercise programs, passive
exercises and range-of-motion therapies not related to
restoring loss of functions are not covered.
Plastic or Reconstructive Surgery
Plastic, cosmetic and reconstructive surgery
examples are:
Liver
Heart
Lung
When necessary to restore function.
Heart and lung
To correct a serious birth defect, such as cleft lip.
Liver and kidney
To restore body form after an accidental injury.
Bone marrow
Limited coverage applies.
Outpatient Services
Some of the covered services may require a copayment.
Diagnostic tests including lab procedures,
x-rays, EKG, EEG
Outpatient surgical procedures and anesthesia
Urgent care services. See Chapter 4 for more
information.
Emergency room visits. See Chapter 4 for
more information.
Pacemaker Monitoring (Telephonic)
Monthly checks
To improve appearance after severe disfigurement or
extensive scarring from surgery for cancer, for breast
reconstruction after a mastectomy resulting from
disease, reduction of the remaining breast, or external
breast reconstruction.
For breast reconstruction after an accident or
if breast was absent at birth.
Breast reductions are covered if medically necessary
and not for cosmetic purposes.
Removal of breast implants is covered if initial surgery
was not for augmentation.
Other limitations apply.
Prescription Drugs
See Chapter 14 for more details.
13
CHAPTER 5:
Preventive Health Services
The Plan covers health exams and screenings that
meet the recommendations of the United States
Preventive Services Task Force. Your PCP determines
how often these need to be done. Examples of covered
screenings are:
Mammograms
Pap smears
Sigmoidoscopy and colonoscopy
Screening for tuberculosis, rubella and hepatitis
Blood pressure and cholesterol checks
Age appropriate immunizations
Comprehensive eye exams
Others, as listed on the table on page 18
Well-Child Care
Well-child care for children up to 17 years of age is
covered. See Chapter 7.
Covered care includes:
Newborn exams
PKU tests
Circumcision
History and physical exam
Vision screening provided by your child’s PCP
Hearing screening provided by your child’s PCP
Dental screening provided by your child’s PCP
Developmental evaluation
Immunizations (for DTaP, polio, measles, mumps,
rubella, chicken pox, HiB, Hepatitis B, etc.)
An annual physical is a covered benefit. Women may also
have one well-woman exam annually performed by a
plan obstetrician/gynecologist without a PCP referral.
Tuberculin tests (TB skin test)
Skilled Care
The Plan covers skilled nursing. Any medication not
covered by the facility will be covered if obtained through
a network pharmacy or Maxor Mail Order Pharmacy.
Special blister packaging is available if required. Contact
your Maxor Pharmacy for more information.
Urinalysis
Urgent Care
Blood tests for anemia
Lead assessments as medically needed
Routine well-child care
Physicals for ages 5–11 that are required for school
No verbal statement from anyone should affect these
benefit limitations and exclusions in any way. Nor should
verbal statements be used in the prosecution or defense
of a claim under this plan.
CIRCUMSTANCES BEYOND PLAN
CONTROL
In the event of major disaster, epidemic, war, terrorist
activity, riot, civil insurrection, disability of a significant
number of Plan providers, complete or partial
destruction of facilities, or other circumstances, The
Plan will make a good faith effort to provide or arrange
for covered services.
14
CHAPTER 6:
OUT-OF-AREA COVERAGE
When you are outside of the service area, The Plan will
cover medical emergency services provided by licensed
physicians and hospitals.
For emergency services, please call the emergency
information number within 24 hours. This number
(1-800-678-7347) is listed on your membership card.
An emergency is defined as a medical, maternity
or psychiatric event that would lead a “prudent
layperson” to believe that a serious medical
condition existed. Or the absence of medical
attention would result in a threat to his/her life,
limb or sight and requires immediate medical
treatment. These emergency conditions would
reveal severely painful symptoms, requiring
immediate care to relieve suffering. This includes
situations where a member has severe pain.
Please note that this call is not an approval for payment
of emergency care services. You should also contact your
PCP before receiving that care, when possible. Your PCP
must schedule any follow-up care. Emergency services,
including prescriptions, given outside of the service
area are not covered if the need for care could have been
foreseen before leaving the service area. Emergency care
is reviewed after time of service.
Note:
Examples of medical emergencies include heart attacks,
strokes, severe bleeding, poisoning, loss of consciousness
or breathing, and seizures, which are often symptoms of
serious illnesses.
Prescriptions written by emergency room physicians
to be filled outside of the ER must be filled by a network
pharmacy (see page 32 for a listing) or at a CVS pharmacy.
If a network pharmacy is not available, you’ll need to pay
for the prescription and submit your receipts to a Maxor
Pharmacy for repayment. Repayment will be made only if
the visit was deemed emergent in nature.
The Plan must be notified of all medical care that is out-ofnetwork. The network includes all providers listed in the
provider directory (www.USFamilyHealthPlan.org or call
Member Services at 1-800-678-7347).
15
CHAPTER 7:
SCHEDULE OF COPAYMENTS
comprehensive
Meritain.
/Ambulato
/Ambulatory Surgical Facility)
16
CHAPTER 7:
Tier 1 Generic $5 copayment
Tier 2 Brand Name Preferred
and Approved Non-Preferred
$17 copayment
Tier 3 Non-Formulary
(designated by DoD quarterly)
$44 copayment
up to a 30-day supply
$17 copayment
$44 copayment
$17 copayment
$44 copayment
$13 copayment
$43 copayment
up to a 90-day supply when
physician authorized
$13 copayment
$43 copayment
$13 copayment
$43 copayment
Up to 17 years of age, not associated with a preventive service.
17
CHAPTER 7:
Age appropriate immunizations are provided for vaccine preventable diseses
according to guidelines set forth by the Centers for Disease Control.
http://www.cdc.gov/vaccines/pubs/ACIP-lIst.htm
18
CHAPTER 8:
THE TRICARE PRIME UNIFORM BENEFIT
DOES NOT COVER THE FOLLOWING
SERVICES:
GENERAL EXCLUSIONS
Care or charges happening before you were covered
by The Plan
Services provided after the date your coverage ended
under The Plan
Charges for services that you or your covered family
member are not required by law to pay
Charges for services you or your covered family
members would not have had if no coverage existed
Charges for:
• Telephone consultations
• Missed appointments
• Completion of medical reports
• Completion of certifications
Costs of services and supplies that are over the allowed
cost or charge
Services not listed as covered services in this handbook
Services provided by people who live in your household,
or
• the household of your covered dependent, or
• who are related by blood, marriage or legal adoption
to you or your covered dependent
Services and drugs not ordered by your doctor or
approved by The Plan for selected drugs
Services not considered medically necessary or covered
for your diagnosis and/or treatment
Care in a hospital and supplies for hospital care that can
be provided in a lower level of care
Services which are experimental or of a research nature
(See Chapter 18 titled “Other” for more information.)
WHAT IS NOT COVERED
Services and supplies (including inpatient facility costs)
provided by an unauthorized provider
Services provided for:
• Education
• Elective travel
• Employment
• Licensing
• Immigration
• Other administrative reasons
Any services not approved by The Plan or the behavioral
health provider
Care or treatment as a result of being engaged in
an illegal occupation or commission of, or attempted
commission of, a felony or assault
Complications due to a non-approved or noncovered procedure
Unproven drugs, devices, and medical treatments
or procedures
SPECIFIC EXCLUSIONS
The Plan does not provide coverage for:
Acupuncture or acupressure*
Air conditioners, humidifiers, dehumidifiers or purifiers
Ambulance services that are not approved
Autopsy and post-mortem exams
Aversion therapy for substance use disorder
Bed-wetting correctional devices
Breast implants or removal of implants for cosmetic
reasons (see Chapter 5 for more information)
Chair lifts
Chiropractic services*
Cosmetic, plastic or reconstructive surgery not
connected to an approved medical treatment
Services and supplies (including inpatient facility costs)
related to a non-covered condition or treatment
19
CHAPTER 8:
Custodial or convalescent care. Custodial Care is
defined in 32 CFR 199.2 as “treatment or services,
regardless of who recommends such treatment or
services or where such treatment or services are
provided, that:
a. can be provided safely by a person who is not
medically skilled, or
b. is given mainly to help the patient with the
Activities of Daily Living (ADL).”
Domiciliary care. The term “domiciliary care”, as
defined in 32 CFR 199.2, means care provided to a
patient in an institution or homelike environment
because:
Eye or vision correction (except as required by
cataract surgery)
• Eyeglasses and fittings*
• Frames and fittings*
• Contact lenses and fittings*
Food, supplements and vitamins outside a hospital,
except for home nutrition therapy given through
a vein
Routine foot care, except for systemic diseases such
as diabetes
Genetic tests (limited coverage)
Hair transplants
a. providing support for the activities of daily living
in the home is not available or is unsuitable, or
Health club membership
b. members of the patient’s family are unwilling to
provide the care.
Hearing exams, except in treatment of a covered
illness or injury*
Dental care (routine)*, some dental services and
associated prescriptions for preventive care:
• Dental care that is not a medical emergency
such as facial injuries or is not related to a
medical condition such as a complication
of radiation therapy
• Dentures
• Removal of wisdom teeth
General use equipment, such as shower chairs, air
cleaners or whirlpools
Hearing aids*
Home changes such as:
• Installation of covered DME
• Entrance ramp
• Elevator
Hot tubs
Housekeeping, homemaker, attendant services,
or sitter or companion services (except with
hospice care)
Learning disorder treatment, including dyslexia
Education or training (except education for
preventive services and network diabetic education
programs)
Massage therapy*
Electrolysis
Mind expansion
Elevators
Naturopath services*
Exercise equipment
Nutritional therapy that is not medically necessary
and not the primary source of nutrition
Exercise (general or maintenance) programs, even if
ordered by a doctor
Eye exercises or visual training (orthoptics)
Eye surgery
• Radial Keratotomy
• Lasik*
• Other elective visual correction surgery
20
WHAT IS NOT COVERED
Megavitamin and orthomolecular
psychiatric therapy
Over-the-counter (OTC) drugs not approved
by the Department of Defense (DoD) (examples:
vitamins, minerals and food supplements)
Orthodontia
CHAPTER 8:
WHAT IS NOT COVERED
Orthopedic appliances such as shoes and arch supports,
except when part of a brace:
Respite care
• Arch support
• Shoe inserts
• Other supportive devices of the feet (wedges, specialized
fillers, heel straps, pads, shanks)
• Cranial orthosis, etc.
Service animals
Physical exams for employment
Prescription drugs used for cosmetic purposes
Private duty nursing in addition to the nursing staff of a
hospital, retirement home or home for the aged
Private hospital rooms unless ordered by the doctor for
medical reasons, or if a semiprivate room is not available
Psychotherapy (elective)
Reproductive treatment such as:
• artificial insemination,
• in-vitro fertilization, and
• any other therapies (including medications)
to induce pregnancy
Retirement homes
Sex change treatment or sex therapy
Smoking cessation programs*
Spas
Surgical sterilization reversals
Swimming pools
Telephone services or advice including remote
monitoring and consultation, except for telephonic
pacemaker monitoring
Transportation services except medically necessary
ambulance trips or those approved by the Department
of Defense (DoD)*
Weight control or weight reduction services and
supplies (including prescription drugs)
Obesity surgery coverage has limitations and
requires approval
Whirlpools
Wigs (except for malignant disease conditions)
Work related injuries
Note: Services that are in conflict with the
Catholic Doctrine will not be provided by
CHRISTUS Health facilities. If those services are
part of the Uniform Benefit, they will be offered
through alternative arrangements (see Chapter 5,
What is Covered by The Plan).
*TRICARE does not cover these items. The Plan
offers discounted services for starred (*) items
above. See the Enhancements Section (Chapter 16)
for more information.
21
CHAPTER 9:
CLAIMS AND BILLING INFORMATION
THE CLAIMS PROCESS
BALANCE-BILLING
You don’t have to worry about completing and
submitting claim forms, unless you receive outof-network emergency care. Your PCP or The
Plan provider you were referred to will submit
a claim for covered services.
As a plan member, you may be referred to a non-network
or non-participating provider. There may be an attempt
by the provider to collect payment from you. This
practice is called balance-billing. With balance-billing,
the provider attempts to collect fees that exceed the
TRICARE allowable fee.
The Plan is committed to processing claims from
providers delivering your care. The Plan is also
committed to processing claims in a timely manner. If
you feel that claims have been processed incorrectly or
are in error, please contact Member Services at 1-800678-7347. Member Services will explain the appeal
process to you and instruct you further. If you prefer, you
may send a written appeal to:
Attn: Claims Appeals
P.O. Box 169001
Irving, TX 75016
Please be sure to include the following in your letter:
Member ID number
Patient’s name
Provider listed on the claim
The date of service
In the event of a disputed claim or appeal, there
is a process The Plan must go through to resolve
the issue. You will be notified of the outcome of
the appeal.
If you receive a bill from a provider relating to services
you received, please forward those bills to the following:
P.O. Box 169001
Irving, TX 75016
IF YOU GET A BILL BY MISTAKE
There are no claim forms, bills or balance-billing for
services covered by The Plan. You should only have to
pay required enrollment fees or copayments (see page 16
for more details on costs).
IF YOU PAY A BILL YOURSELF
If you receive care and pay the bill yourself, you
can submit proof of your payment and a copy of
the bill for consideration (reference page 8 for “Coverage
for Emergency Care”). Please include your member ID
number on the bill before sending it to The Plan at:
Attn: Claims
P.O. Box 169001
Irving, TX 75016
We will review it and reimburse according to
your Plan benefits.
22
CHAPTER 10:
MEMBER INQUIRIES AND PROBLEMS
The Plan urges you to resolve questions, concerns or
problems at the point of service. If your concern is not
solved at the point of service, you have two options:
Please contact Member Services at 1-800-678-7347
You may also contact your local patient advocate
for help
Formal Grievance
If your concern has not been solved through Member
Services, you may submit a written complaint. The written
complaint should contain:
Your name, address and member ID number
GRIEVANCES AND APPEALS
Appeals must be written. Include all information to
support your request and send the appeal to:
Attn: Medical Appeals
P.O. Box 169001
Irving, TX 75016
For most appeals, review is done by The Plan. If
all necessary information is available, a decision
is made within 30 calendar days. The Plan follows
Deparment of Defense (DoD) guidelines.
Per the Department of Defense (DoD), you may have the
right to an expedited appeal when:
A summary of the complaint/question
you are in a facility, or
Any prior contact made with The Plan and a
description of help sought
before an admission or procedure
Your signature and date
Mail your complaint to:
Attn: Manager, Member Services
P.O. Box 169001
Irving, TX 75016
The following timeframes apply:
Concurrent Review (member is in the hospital)
• Appeal requests must be sent by noon the day
following the day the denial was received.
Expedited Pre-admission/Pre-procedure – Requests
must be sent within three (3) calendar days after the
receipt of the first denial.
All other appeals – Requests must be sent within
ninety (90) days after the date of the first denial.
Written complaints often need investigation. Please be
patient during this process. A plan representative or
provider may contact you during or after the investigation
of a complaint.
The Plan will respond by written letter to appeals within
the following time frames:
Appeals
There may be times when you are not satisfied with The
Plan’s decision to deny care. Medical necessity issues and/
or coverage benefit issues may be reasons why care may
be denied. You have a right to request a review of the
decision (appeal).
Expedited Pre-admission/Pre-procedure – Three (3)
calendar days after receipt of the appeal request.
Concurrent Review – Total time for the appeal process
should be no more than three (3) business days from
the receipt of the appeal request.
All other requests – Thirty (30) calendar days after
receipt of the appeal request.
23
CHAPTER 11:
COORDINATION WITH OTHER HEALTH INSURANCE
COORDINATION OF BENEFITS (COB)
DOUBLE COVERAGE AND THIRDPARTY LIABILITY
Some plan members have other health insurance.
Examples are Blue Cross Blue Shield, Aetna, or
Medicare or Medicaid plans. The Plan and the
Department of Defense (DoD) require that you
report any other health insurance. Under federal
law, The Plan pays only for charges remaining after
all other insurance has paid. The Plan collects this
information in order to coordinate benefits with
your other health insurance. This is known as
“Coordination of Benefits” (COB).
Providing your other health insurance coverage
information does not reduce any plan benefits.
If you or your family members change your insurance
coverage, please notify US Family Health Plan at
1-800-678-7347.
24
Third Party Liability
The Federal Medical Care Recovery Act (42
U.S.C.2651-2653) provides for the recovery of medical
care costs paid by the United States. This applies if a
person has a disease or injury caused by actions or
negligence of a third party.
For example, a member is injured as a result of an
automobile accident and TRICARE paid for care. Under
this act, the government may recover the amounts paid
by TRICARE.
It is your responsibility to inform US Family Health Plan
of all injuries or accidents. Call 1-800-678-7347.
CHAPTER 12:
The Plan encourages members to make
decisions about medical care and business
before they are needed. We also encourage
you to talk to your family about the care you
want and your business decisions. Your
PCP also needs to know what you want for
your medical care and treatment. These
decisions can include:
What you want done for your medical care treatment
if you cannot make medical decisions for yourself.
• This includes your wishes about life support.
• It may also include naming someone to make
decisions for you.
If you want to name another person to make business
and financial decisions for you. This includes decisions
about your government benefits and insurance.
If you want to give someone permission to review and
discuss your medical records with your doctor. This is
not the same as naming someone to make decisions
about your care.
Your decisions need to be in writing. This way, you can
give copies to your doctor and your family.
The following information and forms may be helpful. The
Plan cannot give you legal advice. There is no guarantee
the sample forms in this manual will meet all your needs.
If you have any questions about what you should do or
sign, we recommend you talk to a lawyer.
IMPORTANT DOCUMENTS
SAMPLE FORMS:
1.) Advance Directive (Texas Statutory Advance
Medical Directive). This form is also called
DIRECTIVE TO PHYSICIANS AND FAMILY
OR SURROGATES.
Sometimes this form is called a “living will.” A living
will tells your doctor what kind of care you would like to
have if you cannot make medical decisions. This could
happen if:
You are in a coma, or
You are very sick temporarily.
When you are admitted to a hospital, the hospital staff will
talk to you about living wills. Key things to remember are:
The hospital will offer information and forms for a
living will when you are admitted.
If you have a living will, take a copy with you for any
planned admission to the hospital.
Make sure the person(s) named to make decisions for
you knows where your living will is located.
In an emergency, they will need to bring a copy to
the hospital.
A good living will describes the kind of treatment you
want. Deciding what you want could depend on how sick
you are. For example, your living will can describe what
kind of care you want if you have an illness that you are not
likely to recover from. It can also say what you want if you
are permanently unconscious.
Living wills usually tell your doctor that you don’t want
certain kinds of treatment. It can also state that you do
want a certain treatment, no matter how ill you are.
25
CHAPTER 12:
You can write a living will in several ways:
Your doctor may provide a form for you to use
Write your wishes down yourself
Call your state health department or state
department on aging to get a form
You can download a form from the state
health department
Talk to an attorney
Use a computer software package for legal documents
Living wills do not have to be complicated legal
documents. They can be short, simple statements about
what you want done or not done if you can’t speak for
yourself. Remember, anything you write by yourself or
with a computer software package must follow your
state’s laws. You may also want your doctor or a lawyer to
review what you write. This step will help make sure your
directions are understood exactly as you want. When you
are satisfied with your directives, the advance directive
should be notarized, if possible. Copies should be given
to your family and your doctor.
You may change or cancel your living will at any time,
as long as you are considered of sound mind to do so.
Being of sound mind means that you are still able to
think rationally and communicate your wishes in a clear
manner. Again, your changes must be made, signed
and notarized according to the laws in your state. Make
sure that your doctor and any family members who
knew about your directives are aware that you have
changed them.
If you do not have time to put your changes in writing,
you can make them known while you are in the hospital.
Tell your doctor and any family or friends present exactly
what you want to happen. Usually, wishes that are made
in person will be followed instead of the ones you made
earlier in writing. Be sure everyone you have told clearly
understands your instructions.
The best time to prepare a living will is while you are
healthy and still able to make decisions for yourself.
26
IMPORTANT DOCUMENTS
2) Statutory Durable Power of Attorney
This document gives the person you name as your
representative the power to make non-health care
decisions for you according to your wishes. This includes
such things as making decisions about your benefits and
any insurance. You may limit the scope and duration of
the representative’s power of attorney if desired.
3) Medical Power of Attorney
This is an important legal document. It gives the
person you name as your representative the power
to make any and all health care decisions for you,
except to the extent you state otherwise. These
include decisions based on your religious and moral
beliefs, when you are no longer capable of making
them yourself. Your chosen representative will make
these decisions according to your wishes.
4) Texas Department of State Health Services
Standard Out-of-Hospital Do-Not-Resuscitate
(DNR) Order Form
Emergency medical personnel are required to start lifesaving measures if needed. This is true, even if you have
signed a living will/Texas Statutory Advance Directive.
You can also sign a Texas Department of State Health
Services Standard Out-Of-Hospital DNR form. If you
do not want life-saving measures, this document
authorizes emergency personnel not to do them. If you
decide to complete this form, be sure that your family
and friends know. You should keep a copy with you at
all times. If you are receiving medical care in your home,
post a copy of the signed form where it is visible to
emergency personnel.
The back of this directory (see pages 69–70) contains
these forms for your convenience. The Plan does not
recommend using these forms and information in place
of the advice or direction of legal counsel.
CHAPTER 13:
FREQUENTLY ASKED QUESTIONS (FAQS)
MEDICARE AND THE PLAN
TURNING 65
Q. Can I keep both Medicare and The Plan?
Q. I am turning 65. Do I have to leave The Plan?
A. Yes. We urge you to keep your Medicare coverage.
If you have Medicare Part B, there are no enrollment
fees and no copays for any services except for
pharmacy prescriptions.
A. If you were a member on September 30, 2012,
you may remain in The Plan after age 65. However,
you cannot re-enroll in USFHP if you are disenrolled
for any reason.
If you became a member after September 30, 2012
you will be disenrolled from The Plan upon reaching
age 65.
Q. How does Medicare affect my coverage under
The Plan?
A. Your coverage stays the same under The Plan. You
have no enrollment fees or copays (except copays
for pharmacy prescriptions). It is important that you
do not use your Medicare benefits while enrolled in
The Plan unless it is for a Medicare service that is not
covered by The Plan.
Q. I am turning 65 years old soon. Should I get
Medicare B?
A. We strongly recommend that you get Medicare B
when you reach the age of 65. Medicare covers some
services not covered by TRICARE Prime. If you do
not get Medicare Part B when it is first offered, you
may have to pay a penalty in order to get Medicare
Part B later.
Q. Can I stay in The Plan without Medicare Part B?
A. Yes, you do not have to participate in Medicare B to join
The Plan. We strongly urge you to take Medicare Part B for
the reasons stated above.
Q. I am turning 65. Do I need to notify The Plan?
A. YES, if you subscribe to Medicare Part B, please
send a copy of your Medicare card as soon as you
receive it to ensure your enrollment information is
correct. Once The Plan receives proof of Medicare
Part B, your enrollment and copay fees will be waived
(not including pharmacy).
COPAYMENTS
Q. Do I have to pay a copay for outpatient surgery?
A. Yes, there is a $25 copayment fee for outpatient
surgery if you are a member without Medicare B.
Please see the copay schedule on page 16, for a
complete schedule of copays.
Q. What is the copay for an ER visit?
A. There is a copayment for each ER visit. Please see
the copay schedule on page 16 for a complete schedule of
copays.
27
CHAPTER 13:
FREQUENTLY ASKED QUESTIONS (FAQS)
PROVIDERS
DENTAL SERVICES
Q. What types of physicians do you have?
Q. Does The Plan offer dental care?
A. A complete listing of our providers and their locations
is available by calling Member Services at 1-800-678-7347
and on our website at www.USFamilyHealthPlan.org
A. No. Routine dental care is not a covered benefit under
The Plan. As an enhancement, The Plan has negotiated
discounts for members. For more information about
The Plan’s Dental Enhancements program, see Chapter
16. For more information about the TRICARE Dental
Program, please visit www.tricare.mil
Q. How can I change PCPs?
A. You can change your PCP by completing the PCP
change form found on page 45 of this handbook.
You may download a copy from our website at www.
USFamilyHealthPlan.org. You can mail the form (P.O.
Box 169001, Irving, TX 75016) or fax it to (281-9367919). You may change PCPs every 30 days.
ENROLLMENT FEES
Q. How much are my annual enrollment fees?
A. The annual enrollment fee is $273.84 per individual
retiree or family member; $547.68 per family of two
or more. The enrollment period is 12 full months. The
enrollment fee may be paid in full, billed in four quarterly
installments or paid by monthly allotments from your
retirement benefits. The quarterly fee is $68.46 per
individual retiree or family member; $136.92 per family
of two or more. The monthly fee is $22.82 per individual
retiree or family member; $45.64 per family of two or
more. You may pay by personal check, cashier’s check,
money order, electronic funds transfers (EFTs), or bill
to your MasterCard or Visa credit card. We cannot take
bank drafts or cash. For more information, see Chapter 2.
Q. When are enrollment fees due?
A. Quarterly payments and monthly allotments are
always due by the 1st of the month. To make sure your
payment is received timely, please mail it no later than
the 20th of the prior month. If you do not receive your
invoice, please call Member Services at 1-800-678-7347.
For more information, see Chapter 2.
28
ANNUAL EYE EXAM
Q. How can I get my annual eye exam?
A. You may visit any network optometrist or
ophthalmologist listed in the provider directory. These
are the only providers that may provide the annual
eye exam. Please refer to Covered Benefits located in
Chapter 5 of the Member Handbook for more detailed
information.
Q. What is the difference between the eye care
providers listed in the provider directory and the eye
care providers located in the Enhancement section?
A. The Plan has contracted with many eye care providers
who are listed in the Enhancement section. These
providers offer discounts for services such as eyeglasses
and contacts. If you receive your annual eye care at their
facilities, US Family Health Plan will not reimburse it.
Q. Why do you want to know about my “other
health insurance?”
A. By having this information, US Family Health
Plan can coordinate benefits with your commercial
insurance. This is a requirement by the Department of
Defense (DoD). There may be certain times where your
commercial insurance will pay first before US Family
Health Plan.
We update the FAQs regularly on our
website. If your question is not answered,
visit the FAQ section of our website at www.
USFamilyHealthPlan.org or call Member Services
at 1-800-678-7347.
CHAPTER 14:
PHARMACY BENEFITS
WHAT’S COVERED
The TRICARE Uniform Formulary covers most FDA
approved prescription drugs. Some prescription drugs
have TRICARE requirements:
Prescription drugs are covered under The Plan:
when ordered by your PCP or an approved
specialist you were referred to and
for prior authorizations, and
for limits on how much can be dispensed
at one time.
filled at a Maxor Pharmacy or other network
pharmacy and
For more information on the TRICARE Uniform
Formulary, please check the website pec.ha.osd.mil/
formulary_search.php
if the drug is on the TRICARE Uniform Formulary.
YOUR COSTS
FORMULARY DRUGS
Generic (Tier 1)
Brand Name (Tier 2)
NON-FORMULARY
DRUGS (Tier 3)
Mail-Order Pharmacy
(up to a 90-day supply)
$0
$13
$43
Local Network Pharmacy
$5
$17
$44
TYPE OF PHARMACY
Non-Network Pharmacy/
Point of Service (POS)
50% of total cost applies after Point
of Service (POS) deductible is met
All the tier 3 medications have medical criteria
established by the Department of Defense (DoD).
The health plan is required to follow these. You may
qualify for the $13 or $17 brand copay or the $0 or
$5 generic copay if your doctor documents medical
necessity for the drug. The prescription is still subject
to approval by The Plan. Please contact your local
Maxor Pharmacy for more information.
HOW TO GET PRESCRIPTIONS FILLED
See page ii for the Quick Reference Guide or
page 32 for a complete list of network pharmacies.
Maxor Pharmacies
Maxor Pharmacies are available for ALL of your
pharmacy needs. This includes first-time prescriptions
and refills. Pharmacists are available to speak with
you for medication education and review of your
medications, and to answer pharmacy benefit
questions.
50% of total cost applies
after Point of Service (POS)
deductible is met
Other Network Pharmacies
Other network pharmacies are available for first-time
prescriptions and refills. You can explore cost-saving
options through Maxor’s Mail Order Pharmacy Service
(see below). Pharmacists are available to speak with you
for medication education.
CVS Pharmacies
For your convenience, CVS pharmacies are available
nationwide for a first-time prescription or an
emergency prescription. You must present your plan
member ID card. Copays apply at the time you receive
your prescription. Pharmacists are available to speak
with you for medication education.
CVS pharmacies are approved only for first-time and
emergency prescriptions. If your doctor writes a new
prescription for a drug you have taken or are taking,
this prescription is not a first-fill.
29
CHAPTER 14:
PHARMACY BENEFITS
HOW TO REFILL PRESCRIPTIONS
HOW TO USE MAIL ORDER
Do not allow yourself to run completely out of
your medication before asking for a refill.
To get started with a new prescription:
Ask your doctor to write a prescription for the
maximum supply allowed (up to a 90-day
supply on most medications).
All refills must be from a Maxor Pharmacy or
other network pharmacy.
See page 32 for a complete pharmacy list and
phone numbers.
Have your doctor fax or call your prescription to
Maxor Mail Order. You can also complete the Maxor
Mail Order Form, including payment information.
Mail the prescription, form, and payment to:
If your prescription was filled at CVS first:
Call a Maxor or other network pharmacy to
transfer the prescription.
Provide the pharmacy with the following information
from your CVS prescription bottle label:
• Pharmacy name
• Pharmacy telephone number
• Patient name
• Prescription number
• Drug name
To transfer a prescription:
Remember to allow at least a 24-hour business
day for processing.
If your prescription was filled at a Maxor
Pharmacy or other network pharmacy:
Call the pharmacy directly with your refill
number(s) located on the bottle
Allow at least a 24-hour business day for processing
If you are out of refills, your doctor will have to
approve more refills before the prescription can
be filled. After you order your refill, the pharmacy
will contact your doctor to get the refill approval.
Remember to allow at least 3 business days for
your doctor to respond before the pharmacy can
fill your prescription.
Mail-order pharmacy service:
You can save nearly 75% on your prescriptions when
you use the mail-order pharmacy. In fact, generic
prescriptions are FREE. You can get up to a 90-day
supply of medication for a lower copay than a 30-day
supply filled at a Maxor or other network pharmacy. Your
prescriptions will be delivered directly to you. You can
save gasoline, time and money.
30
Maxor Mail Order
P. O. Box 32050
Amarillo, TX 79120
Allow 14 days for medication delivery.
Call Maxor Mail Order toll free at 1-866-408-2459 and
select the option to “request a prescription transfer.”
Give the following information to the customer
service staff:
• Pharmacy name
• Pharmacy telephone number
• Patient name
• Prescription number
• Drug name
Make sure the Maxor Mail Order has your
correct address and phone number.
Allow 14 days for medication delivery.
Ordering Refills from Maxor Mail Order:
Refills can be requested by phone (toll free
1-866-408-2459), internet (www.maxor.com) or mail.
If your prescription bottle indicates, “REFILLS 0,”
you are out of refills. The pharmacy will fax your
doctor for approval. Please allow an additional
2-3 business days.
Helpful reminder – always allow 14 days for mail
order medication delivery.
Faxes:
Maxor Mail Order can only accept faxed prescriptions
directly from the doctor’s office.
CHAPTER 14:
Controlled Medication:
Controlled prescriptions ordered by mail are limited
to a 30-day supply.
Address Changes:
Please inform Maxor Mail Order any time your address
or phone number changes, even if it is temporary.
Wrong addresses can delay delivery or receipt of
your prescriptions.
FAMILY PLANNING
For questions about family planning services, call
Meritain at 1-888-627-8889.
For questions about obtaining contraceptives, call
Maxor Pharmacy at 1-866-408-2459.
The Maxor Mail Order Pharmacy, other network
pharmacies and CVS pharmacies will fill birth
control prescriptions.
We suggest you ask your doctor for a 30-day prescription
for immediate use and a 90-day prescription to send to
the Maxor Mail Order Pharmacy.
The usual copays apply for both 30-day and 90-day
mail-order prescriptions. Contact Maxor Mail Order
Pharmacy at 1-866-408-2459 for more information.
Over-the-counter birth control products (i.e.
spermicidal products and prophylactics) are not
covered by The Plan.
Allow 14 days for medication delivery for mail order.
GENERIC AND BRAND NAME DRUGS
The Department of Defense (DoD) requires substitution
of approved generic drugs if they are available.
Brand name products with generic equivalents are
only covered if medically necessary. If you want your
prescription filled with a brand name drug that is not
considered medically necessary, you will be charged full
price for the prescription. The Plan will not pay you back
for the brand name prescription in this case.
Many brand name drugs have generic equivalents that are
chemically identical. According to the FDA, generics are
just as safe and reliable as their brand name counterparts.
The FDA requires that all generic drugs undergo strict
testing to prove they are the same as the brand name
drug. Sometimes, generic drugs are made by the same
manufacturer as their brand name equal.
PHARMACY BENEFITS
DIABETIC SUPPLIES
Diabetic supplies are covered when prescribed by
your PCP or approved specialist. Contact your local
Maxor Pharmacy for the approved brand of glucose test
equipment, test strips, lancets and syringes. Pharmacists
are available at all network pharmacies to demonstrate
how to use your diabetic supplies.
PHARMACY FOR LONG-TERM CARE
FACILITIES (NURSING HOMES AND
ASSISTED LIVING FACILITIES)
Members in a long-term care facility must order their
prescriptions from Maxor Mail Order Pharmacy, Maxor
Pharmacy or another network pharmacy. Maxor Mail
Order Pharmacy and the local Maxor Pharmacies
can package prescriptions in unit doses (blister-pack).
Maxor Mail Order can mail prescriptions directly to the
facility. Prescriptions filled by the long-term care facility’s
pharmacy will not be covered.
FREQUENTLY ASKED PHARMACY
QUESTIONS
How can I minimize my out-of-pocket expense?
Ask your doctor to prescribe generic medication when
possible. Generic drugs have the lowest copay.
Fill your maintenance drugs through the mail-order
pharmacy. You will save nearly 75% on your copay; in
fact, generic drugs are free. You can receive up to a 90day supply for a lower copay than a 30-day supply
from your local network pharmacy.
How can I get my prescriptions in case of a declared
federal or state disaster?
Keep a 10-day supply of medication on hand at all times.
Take your actual prescription bottles or vials with you.
Go to the nearest CVS pharmacy. Call Maxor Plus at
1-800-687-0707 if there is no CVS pharmacy near you.
This number is also located on the back of your ID card
under Pharmacy Claims Problems.
In the event of a declared federal or state disaster,
Maxor Plus will be staffed 24 hours per day.
31
CHAPTER 14:
Maxor and Other Network Pharmacies
Mail Order
Maxor Mail Order Pharmacy
P. O. Box 32050 • Amarillo, TX 79120
1-866-408-2459
www.maxor.com
Clear Lake Area
Maxor Pharmacy
1046-B Hercules Ave • Houston, TX 77058
281-480-0327
24-hour refill line 1-800-687-8429
Cypress Area
Randalls Pharmacy
**this Randalls location only**
12312 Barker Cypress • Cypress, TX 77429
281-373-2507
Galveston Island
CVS pharmacy
409-763-3444
CVS pharmacy
2326 61st Street • Galveston, TX 77551
409-740-0276
Houston Area (Downtown)
Maxor Pharmacy
1919 La Branch • George W. Strake Bldg
713-759-9040
Jasper Area
Walmart
**this Walmart location only**
409-384-1707
Katy Area
Katy Pharmacy I
281-578-1515
32
PHARMACY BENEFITS
Lake Charles Area
CVS Pharmacy
366 Sam Houston Jones Pkwy
Lake Charles, LA 70611
337-855-1341
CVS Pharmacy
2000 Ryan St • Lake Charles, LA 70601
337-439-4241
CVS
4828 Nelson Rd • Lake Charles, LA 70605
337-477-9068
CVS Pharmacy
337-625-2660
Southeast Texas
Market Basket – Beaumont
**emergency and first-fill prescriptions only**
3955 Phelan Blvd • Beaumont, TX 77706
409-892-3226
Maxor Pharmacy
3701 Highway 73
Inside CHRISTUS Outpatient Building
409-989-5643
Sugar Land Area
Ed’s Pharmacy
281-499-4555
Willowbrook Area
Inwood Pharmacy
13300 Hargrave Rd., Ste. 180
Houston, TX 77070
281-664-8829
CVS Pharmacies
Emergency, initial and first-fill prescriptions:
CVS pharmacy nationwide – call 1-888-607-4287 for
the closest location.
CHAPTER 15:
BEHAVIORAL HEALTH SERVICES,
ALCOHOLISM, SUBSTANCE ABUSE,
CHEMICAL DEPENDENCY TREATMENT
The Plan provides coverage for:
Mental health treatment
Substance abuse treatment (includes alcoholism)
Behavioral health benefits are provided by APS. Members
must use APS providers for their behavioral health
benefits. Some services require prior approval. For more
information, please call APS at 1-800-406-0022.
INPATIENT TREATMENT
APS providers can order inpatient admission if it is
necessary. Prior approval is required. The Plan
inpatient benefit is:
Members 18 and older: 30 days maximum per plan year
Members under age 10: 45 days maximum per plan year
RESIDENTIAL TREATMENT CENTERS
(RTCS)
RTCs provide residential treatment for children and
adolescents. The Plan covers treatment at a RTC for up
to 150 days.
BEHAVIORAL HEALTH BENEFITS
INPATIENT MENTAL HEALTH
REHABILITATION
The Plan covers up to 21 days of inpatient mental
health rehabilitation per plan year.
Note: These 21 days count in the 30- or 45-day limit
for inpatient. One inpatient admission is allowed in
a plan year. Three inpatient admissions are allowed in
a member’s lifetime.
OUTPATIENT TREATMENT
The Plan provides coverage each plan year for:
60 visits for outpatient treatment for substance abuse
Members can make eight outpatient treatment visits
to an APS provider without prior approval. These
eight visits count in the allowed outpatient visits for
substance abuse.
PARTIAL HOSPITALIZATION
Partial hospitalization is defined as a minimum
of three hours per day at a behavioral health center.
Members are allowed up to 60 days of partial
hospitalization per plan year.
Partial hospitalization days do not count in the
30- or 45-day inpatient limit.
INPATIENT SERVICES FOR DETOXIFICATION
The Plan covers up to seven days of detoxification in a
rehabilitation center.
Note: These seven days count in the 30- or 45-day limit
for inpatient.
33
CHAPTER 16:
This program gives discounts for:
OUR ENHANCEMENT PROGRAM
Transportation
You get a 20% discount on items not covered at
participating providers. You cannot combine the 20%
discount with other discounts or offers. The discount
does not apply to EyeMed providers’ professional
services or disposable contact lenses. Retail prices
vary by location.
Complementary and alternative medicine services
Limitations and Exclusions:
Vision
Dental
Hearing aids
VISION ENHANCEMENT
Your annual eye exam is covered under The Plan.
You can get discounts on other select vision services
through EyeMed.
EyeMed
Go to www.EyeMedVisionCare.com or call EyeMed’s
Customer Care Center at 1-866-723-0513 to request
an ID card or find a provider. Show your EyeMed
Vision Care ID card to a participating provider to get
discounts.* The EyeMed Vision Care network includes:
Optometrists
Ophthalmologists
Opticians
Leading vision retailers:
• LensCrafters
• Target Optical
• Most Sears Optical and Pearle Vision locations
This is not insurance:
This is a supplemental discount.
* Items bought separately will be 20% off the retail price.
** LASIK and PRK vision correction are optional
procedures, and this discount may not be offered in
your area.
Vision training
Subnormal vision aids and related
supplemental testing
Medical procedures, eye surgery or
support services
Corrective eyewear required by an employer
as a condition of employment
Safety eyewear unless specifically covered
under your plan
Services given as a result of any workers’
compensation law
Discount not available on frames if the
manufacturer does not allow a discount
OTHER VISION ENHANCEMENT OPTIONS
Show your plan member ID card for discounts at:
Select TSO offices in Southeast Texas and
Southwest Louisiana
Katy Laser Center (Office of Dr. Erin Doe)
Lone Star Eye Care (Office of Dr. Matthew
McMenemy)
OTHER VISION
CARE SERVICES
MEMBER COST
Contact Lens Exam
Includes exam, fitting and
follow-up
10% discount on
retail prices
Eyewear, excluding
contact lenses
20% discount on
retail prices
Katy Laser Center
Lone Star Eye Care
34
CHAPTER 16:
COMPLEMENTARY AND ALTERNATIVE
MEDICINE (CAM)
Complementary and alternative medicine (CAM) includes
treatment not defined as standard medicine. CAM
treatment options are not covered benefits under The Plan
and TRICARE. We do offer discounts on these services
to plan members through a partnership with Healthways.
Show your plan member ID card at participating providers
to get 10–30% off CAM services.
Acupuncture
Chiropractic
HEARING ENHANCEMENT
Show your plan member ID card at participating Beltone
or AUDIBEL providers in Southeast Texas and Southwest
Louisiana or the office of Monique Jenkins at St. Joseph
Hospital to get the following:
HEARING ENHANCEMENT
MEMBER COST
Annual Hearing Exam
Includes hearing aid evaluation and ear
mold impression
Free
Hearing Aids
Includes behind-the-ear, in-the-ear
canal, completely-in-canal and digitally
programmable remote devices
20% discount on
retail prices
Instrument Dispensing and Post
Fitting Evaluation
Free
Massage therapy
Holistic physicians and practitioners
Nutritional counseling
Tai chi
Yoga
And more
Go to usfhp.wholehealthmd.com to see the
Healthways network.
DENTAL ENHANCEMENT
MPJ Audiology
Consultants, LLC
Show your plan member ID card at:
Any Family & Implant Dentistry
Gerard A. Cascio, D.D.S.
Participating Monarch Dental Associates
to receive the following discounts:
Go to www.USFamilyHealthPlan.org to find a
participating provider near you.
TRANSPORTATION ENHANCEMENT
Access2Care provides eight round-trips (16 one-way
trips) every calendar year
DENTAL
ENHANCEMENT
MEMBER COST
Initial Dental Exam
(X-rays not included)
Free
Additional Services
15% discount
Transportation to medical services covered by The
Plan include:
• Appointments
• Medical procedures
• Dialysis
• Hospital admissions
Transport may be by taxi, shuttle, ambulance and/or
ADA-equipped buses
Call Access2Care at 1-855-242-0347
FAMILY & IMPLANT
Dentistry
35
CHAPTER 16:
EDUCATIONAL RESOURCES
24/7 Health Information/Nurse Hotline
You have a direct line to important health information.
This service connects you with medical information and
advice on most health-related topics.
Plan members have access to a registered nurse 24 hours
a day, seven days a week.
Medline Plus
The Plan encourages you to use Medline Plus at
medlineplus.gov. The US National Library of Medicine
(NLM) and the National Institutes of Health (NIH)
developed and maintain the Medline Plus website.
This site gives members information on:
Diseases
Call 1-800-455-9355 anytime.
Medical conditions
Note: This number is also found on the back of your
member ID card.
Clinical trials
Member Education
The Plan provides regular member education to help
you make healthy lifestyle choices.
Newsletters and Postcards
The Plan sends regular postcards. You will also get
“Well Informed,” our quarterly member newsletter. Our
postcard and newsletter topics include exercise safety,
hurricane preparation, healthy cooking and drug safety.
Workshops
The Plan holds workshops throughout the service area
regularly. These workshops help members with smoking
cessation and weight control.
Flu Shots
The Plan provides free flu shots to members every fall.
You will receive a postcard with more information.
36
Drugs
Current health information
Note: This site is not a substitute for health care
information from your doctor. This is an additional
resource. MedLine Plus is for the general public and
may contain information that is not part of The Plan.
The doctors listed at medlineplus.gov may not be
participating Plan providers.
Please continue to use The Plan’s provider directories at
www.USFamilyHealthPlan.org to choose a participating
provider or call 1-800-678-7347 for more information.
CHAPTER 17:
Plan members who have Medicare or Medicaid may only
use these benefits for services not covered by The Plan.
Examples of these are chiropractic care and End Stage
Renal Disease (ESRD).
The government requires the health plan to monitor your
Medicare or Medicaid usage. You may be disenrolled if
you continue to use Medicare or Medicaid benefits for
services covered by The Plan. This keeps the government
from paying for your care in more than one program. The
government funds all three programs (Medicare, Medicaid
and The Plan).
KIDNEY DIALYSIS (ESRD)
There are special rules for coverage and payment of
chronic kidney dialysis. Members with End Stage
Renal Disease (ESRD) must apply for Medicare coverage.
Most of the time, The Plan provides coverage until the
member qualifies for Medicare. This usually happens
in the third month, after the start of the first course of
maintenance dialysis.
Medicare coverage may begin as early as one month
if the member:
is in a self-dialysis training program in a
Medicare-approved facility,
starts the training before the third month after
dialysis begins, and
expects to complete the training and selfdialysis after that.
MEDICARE USAGE
Medicare Part A insurance is the basic coverage under
Medicare. Medicare Part A coverage begins at age 65.
Part A covers inpatient dialysis related services.
Medicare Part B insurance covers:
doctor’s services,
outpatient hospital services,
dialysis services, and
other health services and supplies.
Medicare Part B is optional. Most of the services and
supplies that people with ESRD need are covered by
Medicare Part B. Medicare Part B has monthly premiums
that are paid by the member.
The Plan encourages all its eligible members to enroll
in Parts A & B. ESRD patients must enroll in Medicare
Part B. The Plan is not allowed to provide coverage for
ESRD after the first three months of care. ESRD patients
without Medicare Part B then become responsible for all
charges related to ESRD. This begins on the first day of the
4th month after starting treatment. Members who have
stopped Medicare Part B before developing ESRD can reapply for this coverage. The Social Security Administration
can give you more information.
Transportation by ambulance for Renal Dialysis must be
approved as medically necessary by The Plan. Approved
ambulance services are limited to travel to and from the
dialysis center.
After a member qualifies for Medicare, The Plan pays
coinsurance charges after Medicare pays. If a member
needs a kidney transplant, Medicare is the primary
coverage for 36 months afterwards.
37
CHAPTER 18:
CASE MANAGEMENT
Case management is available to members who have a
long-lasting disease and who have disease complications.
Case management is a process that works with you and
your family to meet your health care needs.
Case management is not limited to severe illnesses
and injuries.
The Plan’s case managers are registered nurses who
partner with you and your providers. There are no
copayments for these services.
Extended Care Health Option (ECHO)
Important things to know about Extended Care Health
Option (ECHO):
ECHO is a TRICARE supplemental program
ECHO is only available to active duty family members
ECHO members must have a specific qualifying
mental or physical disability
As a plan member, you can enroll in cancer clinical
trials sponsored by the NCI. This provides plan
members with cancer or who are at risk for cancer
access to promising advances in cancer research. The
clinical cancer trials are research studies that help
find ways to:
prevent, diagnose or treat illnesses, and
improve overall health care.
In a cancer clinical trial, you will receive care that is
considered to be the latest in medicine or therapy.
However, the medicine and therapy you will receive
has not yet been approved as “standard care.” Clinical
trials may offer choices for members with limited
treatment options for their cancer treatment.
The cancer treatment trials (also called research
studies) test new treatments on people diagnosed
with cancer. The goal of this research is to find better
ways to treat cancer and help cancer patients. Cancer
treatment trials study many types of ways to fight
cancer. These include testing new:
An enrollment fee is not required for ECHO
drugs,
Members eligible for ECHO must register with their
regional contractor or TRICARE Area Office
approaches to surgery or radiation therapy,
Eligible members must be enrolled in the Exceptional
Family Member Program before they can use ECHO
methods, such as gene therapy.
Eligibility for ECHO must be noted in DOES.
All ECHO services must be authorized by The
Plan’s Case Management Department for care to be coordinated and claims paid.
To learn more, please go to the website for the Military
HOMEFRONT at www.militaryhomefront.dod.mil
CLINICAL CANCER TRIALS
Each year, about 12,000 MHS beneficiaries are diagnosed
with cancer. For this reason, the Department of Defense
(DoD) has partnered with the National Cancer Institute
(NCI) for clinical cancer trials.
38
OTHER INFORMATION
combinations of treatments, and
As a plan member, you are entitled to participate in
NCI clinical trials.
There are more than 2,000 sites throughout the U.S.
Worried about costs? The agreement between the
Department of Defense (DoD) and NCI will cover
costs for screening tests to determine clinical trial
eligibility. This agreement will also cover costs
that can occur as part of participation in cancer
clinical trials. You are only responsible for normal
copayments, even if your provider is not in The Plan
network.
All care must be approved before treatment
can begin.
If you are interested, you should contact your
plan PCP to find out more on the clinical trials
and enrollment opportunities.
US FAMILY HEALTH PLAN NETWORK HOSPITALS
Please remember that this list is subject to change.
1. OakBend Medical Center Williams Way
22003 Southwest Freeway
Richmond, TX 77469
281-341-2000
2. OakBend Medical Center Jackson Street
1705 Jackson Street
Richmond, TX 77469
281-341-3000
3. CHRISTUS St. Catherine Hospital
701 South Fry Road
Katy, TX 77450
281-599-5700
4.Methodist Sugar Land Hospital
16655 Southwest Freeway
Sugar Land, TX 77479
281-274-7000
5. North Cypress Medical Center
21214 Northwest Freeway
Cypress, TX 77429
832-912-3773
10.CHRISTUS St. John Hospital
18300 Saint John Drive
Nassau Bay, TX 77058
281-333-5503
6. Methodist Willowbrook Hospital
18220 Tomball Parkway
Houston, TX 77070
281-477-1000
11.CHRISTUS St. Elizabeth Hospital
2830 Calder Street
Beaumont, TX 77702
409-892-7171
7.St. Joseph Medical Center
1401 St. Joseph Parkway
Houston, TX 77002
713-757-1000
12.CHRISTUS Jasper Memorial Hospital
1275 Marvin Hancock Drive
Jasper, TX 75951
409-384-5461
8.University General Hospital
7501 Fannin Street
Houston, TX 77054
713-375-7000
13.CHRISTUS St. Mary Hospital
3600 Gates Boulevard
409-985-7431
9.The Methodist Hospital at the Texas
Medical Center
6565 Fannin Street
Houston, TX 77030
713-790-3311
14.CHRISTUS St. Patrick Hospital
524 Dr. Michael Debakey Drive
Lake Charles, Louisiana 70601
337-436-2511
39
FORMS:
TABLE OF CONTENTS
ADMINISTRATIVE FORMS
Enrollment Form Help Guide......................................................................................................................43
Instructions are included for your convenience.
Enrollment Application and PCP Change Form.........................................................................................45
Complete the form and mail it to:
P.O. Box 169001
Irving, TX 75016
Enrollment Fee Allotment Authorization Form.........................................................................................51
This form can be used to pay your US Family Health Plan enrollment fee
using your monthly allotment.
Military Health System Notice of Privacy Practices....................................................................................52
You may also download a copy of the US Family Health Plan Privacy
Notice at any time at our website, NEED URL, as well.
LEGAL DOCUMENTS
Texas Statutory Durable Power of Attorney.................................................................................................57
This is the form promulgated by the Texas Legislature for designating an agent
empowered to take certain actions regarding your property and finances.
The statutory basis of this form is Texas Probate Code §490.
Texas Statutory Advance Medical Directive.................................................................................................61
This is the form promulgated by the Texas Legislature for indicating your
wishes in the event you are diagnosed with a terminal or irreversible condition.
The statutory basis of this form is Texas Health and Safety Code §166.033.
Notification of Appointment of Personal Representative...................................................................................65
40
FORMS:
TABLE OF CONTENTS
Privacy Act Statement-Health Care Records....................................................................................................67
Texas Out-of-Hospital Do-Not-Resuscitate Form............................................................................................69
The Out-of-Hospital Do-Not-Resuscitate form allows you to
instruct EMS (ambulance) staff that you do not want to be
resuscitated if you stop breathing and your heart stops beating.
In an emergency, EMS staff does not have access to or information
about your Advance Medical Directive or your medical decision
maker. They are required to start life saving measures unless they
can immediately determine this is not what you want.
Texas Residents: This form allows you to declare that you do not
want certain resuscitative measures used on you if there is EMS
staff taking care of you. Recent changes in the Texas law also
authorize EMS to look for an ID band to alert EMS staff to your
out-of-hospital DNR wishes. For more information about this form,
including where you can purchase an ID bracelet if you want one,
go to www.dshs.state.tx.us/emstraumasystems/dnr.shtm
Louisiana Residents: If you are a resident of Louisiana and wish
to have this form in place, please talk with your primary care
physician. Your physician must sign your Out-of-Hospital DoNot-Resuscitate order if you want one.
Medical Power of Attorney Form.......................................................................................................................71
Except to the extent you state otherwise, this document gives the
person you name as your agent the authority to make any and all
health care decisions for you in accordance with your wishes,
including your religious and moral beliefs, when you are no longer
capable of making them yourself.
41
42
US FAMILY HEALTH PLAN – CHRISTUS HEALTH ENROLLMENT FORM HELP GUIDE
Guide to the Enrollment Form for US Family Health Plan
There are some important differences between US Family Health Plan and other TRICARE plans. To avoid any confusion,
please read these brief guidelines that specifically pertain to US Family Health Plan before you complete the form itself.
If you have any questions or need assistance filling out the enrollment form, don’t hesitate to call us at 1-800-678-7347. We are
happy to help!
Please note:
• If you want to enroll in US Family Health Plan, this is the right form.
• Enrollment is open to military beneficiaries under the age of 64, except for active duty sponsors.
• When you enroll in US Family Health Plan, you choose a PCP (primary care provider). PCP is the same as
PCM (primary care manager), which is a term you’ll see on the standard form. They mean the same thing.
• Our headquarters are in Irving, TX, but enrollment is open to residents throughout our service area,
which covers Southeast Texas and Southwest Louisiana. We have a large number of local doctors and hospitals
serving members in these areas.
• When you mail this form, use this address:
US Family Health Plan, P.O. Box 169001, Irving, TX 75016
Page 1
This is the “TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form” issued by
the Department of Defense. Since US Family Health Plan is a TRICARE Prime option, this is the correct form to use if
you want to enroll with us. (Don’t worry. There are just a few pages that need to be filled out. The enrollment form itself
is only four pages and begins on page 2.)
Form Submission
Mailing the Form – For manual enrollment, you may complete and submit the form to this address:
P.O. Box 169001
Irving, TX 75016
43
Page 2
The form starts here. It’s a four-page form. Please print in ink. Where there are check boxes, place an X in front of your
selection/response. For example, under “TRICARE Prime Option Desired,” place an X in the box in front of Uniformed
Services Family Health Plan (USFHP).
Section I: Complete this section as it pertains to the Sponsor.
Primary Care PCM Preference (Line #10): Instead of merely indicating your preferences for a PCM, you can actually choose
your primary care provider (PCP). Visit www.USFamilyHealthPlan.org and click on Texas. Then, use the “Find a Provider”
search on the right side of the page to search for Primary Care Providers near you. Simply print the name of the doctor you
choose to be your primary care provider (PCP) on line 10a. Your family members should indicate their PCP choices on page 3.
Once you’ve chosen your PCP(s), there’s no need to further describe your preferences – so there’s no need to fill out the other
lines relating to specialty and gender.
Page 3
Section II: Enrolling family members’ information is entered here. If more than three family members are enrolling,
please fill out additional copies of page 3.
Page 4
Section III: You may skip this section because it is not applicable.
Section IV: Please identify if anyone in your family is currently covered by other health insurance.
Section V: You may skip this section because it is not applicable.
Page 5
Section VI - Payment of TRICARE Prime Enrollment Fees: There are no enrollment fees for active-duty family members.
There are no enrollment fees for individuals with Medicare Part B. For everyone else, enrollment fees apply. This section states
that Medicare-eligible members must be enrolled in Medicare Part B to be eligible for enrollment in TRICARE Prime. This is
not the case for enrollment in US Family Health Plan. Medicare Part B is not required to enroll in US Family Health Plan. If
you have Medicare Part B, your enrollment fee is waived, and there are no copayments, except for prescriptions. In the event
that you have Medicare Part B and your spouse does not, payment of your spouse’s enrollment fee is required. Please decide if
you’d like to pay monthly, quarterly or annually. Then, complete this section by placing an X in the appropriate boxes. If you
choose the Monthly Allotment payment option, section A below will apply to you. If you choose the Electronic Funds Transfer
payment option, section B below will apply to you. If you choose the Credit Card payment option, section C below will apply
to you.
A–
MONTHLY ALLOTMENT: Please follow instructions on page 5. Also, complete and send US Family Health Plan Allotment
Authorization Letter with your completed enrollment form.
B–
ELECTRONIC FUNDS TRANSFER: Please follow instructions on page 5. Also, send a voided check with the completed
enrollment form to make sure the information conforms to bank requirements.
C–
CREDIT CARD: Please follow instructions on page 5. Per your payment fee option selection, your credit card will be
charged on a recurring basis. NOTE: This is US Family Health Plan’s approved process.
Questions? Call 1-800-678-7347 during business hours. We can meet with you or help you by phone, providing any
assistance you may need.
44
45
46
47
48
49
50
Enrollment Fee Allotment Authorization Letter
Please type or print all entries.
Name: Last
First
Home Address: Street
M.I.
Apt. No.
SSN
City
State
Zip Code
Indicate below the action you wish to take for the allotment process.
Please mark one of the three boxes and complete the requested information.
Please Start a monthly allotment to USFHP from my retirement pay for USFHP enrollment fees in the amount of:
$__________ (Single $23.55 or Family $47.10)
I have enclosed a payment (personal check, cashier’s check, traveler’s check, money order or credit card) for the initial
*3-month payment ($70.65 individual or $141.30 family) if required.
Please circle card type:
Visa /
MasterCard
Card number: ____________________________________ Exp. ___/___ Amount: $________ Today’s date: ________
Please Change my existing monthly allotment to USFHP from $ __________ to $ __________ .
My status changed as of (MM/YY) _____/_____ .
Single to Family ($23.55 to $47.10)
Family to Single ($47.10 to $23.55)
Please Stop my existing allotment to USFHP so that my USFHP coverage is paid through the last day of
(MM/YY) _____/_____ .
I hereby authorize this allotment to be taken from my military retirement pay. I understand
that it will remain in effect until I request that it be changed or stopped. However, as a
courtesy to me, I also authorize USFHP to automatically stop this allotment at a future date
if I become disenrolled from the USFHP for any reason, including transferring my enrollment
to a different USFHP/TRICARE region.
Signature (Required): _________________________________ Date: _________________
USFHP will attempt to start the allotment from your military retirement pay by the next payment due date. You
will be notiﬁed by USFHP to make alternative payment arrangements if the allotment from your retirement pay
could not be started by this date.
Mail this form with your Enrollment application if completing it as a part of your new enrollment.
Please complete, sign, and mail this form and payment to:
CHRISTUS - US Family Health Plan
PO Box 169001
Irving, TX 75016
1-800-678-7347
MILITARY HEALTH SYSTEM
NOTICE OF PRIVACY PRACTICES
Effective April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.
If you have any questions about this notice, please contact the US Family Health Plan Privacy Officer at the contact
information provided at the end of this notice.
This notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability
Act (HIPAA). The US Family Health Plan is required to comply with HIPAA and with the Texas Medical Privacy Act. This
notice describes how we may use or disclose your protected health information, with whom that information may be shared,
and the safeguards we have in place to protect it. This notice also describes your rights to access and amend your protected
health information.
Who Will Follow This Notice
The US Family Health Plan is part of an organized health care arrangement with and a DBA of CHRISTUS Health and its
subsidiaries. While CHRISTUS Health is subject to the privacy practices required by HIPAA, the US Family Health Plan
privacy practices may differ and are outlined here.
Our Pledge to You
“Protected health information” is individually identifiable health information. This information includes demographics,
(for example, age, address, e-mail address) and relates to your past, present, or future physical or behavioral health or
condition and related health care services. The US Family Health Plan is required by law to do the following:
• Make sure that your protected health information is kept private.
• Give you this notice of your legal duties and privacy practices related to the use and disclosure of your
protected health information.
• Follow the terms of the notice currently in effect.
• Communicate any changes in the notice to you.
We reserve the right to change this notice. Its effective date is included in this notice at the bottom of the last page. We reserve
the right to make the revised or changed notice effective for health information we already have about you as well as any
information we receive in the future. You may obtain a Notice of Privacy Practices by accessing your local US Family Health
Plan website (www.USFamilyHealthPlan.org) or calling customer service at 1-800-678-7347 and requesting that a copy
be mailed to you.
How We May Use Or Disclose Your Protected Health Information
Following are examples for permitted uses and disclosures of your protected health information.
These examples are not exhaustive.
52
By law, we must disclose your health information to you unless it has been determined by a competent medical authority
that it would be harmful to you. We must also disclose health information to the Secretary of the Department of Health
and Human Services (DHHS) for investigations or determinations of our compliance with laws on the protection of
your health information.
Treatment
We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related
services. This includes the coordination or management of your health care with a third party. We may disclose your protected
health information from time-to-time to a hospital, physician, or health care provider (for example, a specialist, pharmacist, or
laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care
diagnosis or treatment. This includes pharmacists who may be provided information on other drugs you have been prescribed
to identify potential interactions. In emergencies, we will use and disclose your protected health information to provide the
treatment you require.
Payment
Your protected health information will be used, as needed, to obtain payment for your health care services. This may
include certain activities the US Family Health Plan might undertake before it approves or pays for the health care services
recommended for you such as determining eligibility or coverage for benefits, reviewing services provided to you for medical
necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay might require that
your relevant protected health information be disclosed to obtain approval for the hospital admission.
Health Care Operations
We may use or disclose, as needed, your protected health information to support the daily activities related to health care.
These activities include, but are not limited to, quality assessment activities, investigations, oversight or staff performance
reviews, credentialling, communications about a product or service, and conducting or arranging for other health care
related activities.
We will share your protected health information with third-party “business associates” who perform various activities (for
example, billing, transcription services) for the US Family Health Plan. The business associates will also be required to protect
your health information.
We may use or disclose your protected health information, as necessary, to provide you with information about treatment
alternatives or other health-related benefits and services that might interest you. For example, your name and address may
be used to send you a newsletter about the US Family Health Plan and the services we offer. We may also send you
information about products or services that we believe might benefit you.
Required by Law
We may use or disclose your protected health information if law or regulation requires the use or disclosure.
Public Health
We may disclose your protected health information to a public health authority who is permitted by law to collect or receive
the information. The disclosure may be necessary to do the following:
• Prevent or control disease, injury, or disability.
• Report births and deaths.
• Report child abuse or neglect.
53
• Report reactions to medications or problems with products.
• Notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
• Notify the appropriate government authority if we believe a member has been the victim of abuse, neglect, or
domestic violence.
Communicable Diseases
We may disclose your protected health information, if authorized by law, to a person who might have been exposed to a
communicable disease or might otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight
We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits,
investigations, and inspections. These health oversight agencies might include government agencies that oversee the health
care system, government benefit programs, other government regulatory programs, and civil rights laws.
Food and Drug Administration
We may disclose your protected health information to a person or company required by the Food and Drug Administration
to do the following:
• Report adverse events, product defects, or problems and biologic product deviations.
• Track products.
• Enable product recalls.
• Make repairs or replacements.
• Conduct post-marketing surveillance as required.
Legal Proceedings
We may disclose protected health information during any judicial or administrative proceeding, in response to a court order
or administrative tribunal (if such a disclosure is expressly authorized), and in certain conditions in response to a subpoena,
discovery request, or other lawful process.
Law Enforcement
We may disclose protected health information for law enforcement purposes, including the following:
• Responses to legal proceedings
• Information requests for identification and location
• Circumstances pertaining to victims of a crime
• Deaths suspected from criminal conduct
• Crimes occurring at a US Family Health Plan site
• Medical emergencies believed to result from criminal conduct
Criminal Activity
Under applicable federal and state laws, we may disclose your protected health information if we believe that its use or disclosure
is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also
disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
54
Military Activity and National Security
When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed
Forces personnel (1) for activities believed necessary by appropriate military command authorities to ensure the proper
execution of the military mission including determination of fitness for duty; (2) to a foreign military authority if you are a
member of that foreign military service. We may also disclose your protected health information to authorized Federal officials
for conducting national security and intelligence activities including protective services to the President or others.
Inmates
We may use or disclose your protected health information if you are an inmate of a correctional facility, and the US Family
Health Plan created or received your protected health information while you were enrolled. This disclosure would be necessary
(1) for the institution to provide you with health care, (2) for your health and safety and the safety of others, or (3) for the safety
and security of the correctional institution.
Disclosures by the Health Plan
Department of Defense (DoD) health plans may also disclose your protected health information. Examples of these disclosures include verifying your eligibility for health care and for enrollment in various health plans and coordinating benefits for
those who have other health insurance or are eligible for other government benefit programs. We may use or disclose your
protected health information in appropriate Department of Defense (DoD)/VA sharing initiatives.
Parental Access
Some state laws concerning minors permit or require disclosure of protected health information to parents, guardians, and
persons acting in a similar legal status. We will act consistently with the law of the state where the treatment is provided and
will make disclosures following such laws.
Uses And Disclosures Of Protected Health Information Requiring Your Permission
In any other situation not covered by this notice, we will ask for your written authorization before using or disclosing your
protected health information. If you choose to authorize our use or disclosure of your protected health information, you can
later revoke that authorization by notifying us in writing of your decision.
Your Rights Regarding Your Health Information
You may exercise the following rights by submitting a written request to the US Family Health Plan Privacy Officer.
Depending on your request, you may also have rights under the Privacy Act of 1974. US Family Health Plan customer service
representatives can guide you in pursuing these options. Please be aware that the US Family Health Plan might deny your
request; however, you may seek a review of the denial.
Right to Request Restrictions
You may request, in writing, a restriction on use or disclosure of protected health information about you for treatment,
payment or health care operations or to persons involved in your care except when specifically authorized by you, when
required by law, or in an emergency. We will consider your request but we are not legally required to accept it. We will inform
you of our decision on your request. All written requests or appeals should be submitted to our Privacy Office listed at the
bottom of this notice.
Right to Inspect and Copy
In most cases, you have the right to look at or get a copy of medical information that we use to make decisions about your care,
when you submit a written request. If you request copies, we may charge a fee for the cost of copying, mailing or other related
supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision.
55
This right does not include inspection and copying of the following records: psychotherapy notes; information compiled in
reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information
that is subject to law that prohibits access to protected health information.
Right to Request Confidential Communications
You have the right to request that protected health information about you be communicated to you in a confidential manner,
such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to use
to communicate with you.
Right to Request Amendment
If you believe that information in our record is incorrect or if important information is missing, you have the right to request
that we correct the records. Your request may be submitted in writing. A request for amendment must provide your reason for
the amendment. We could deny your request to amend a record if the information was not created by us; if it is not part of the
medical or billing information maintained by us; or if we determine that the record is accurate. You may appeal, in writing, a
decision by us not to amend a record.
Right to an Accounting of Disclosures
You have the right to a list of those instances where we have disclosed medical information about you, other than for
treatment, payment, health care operations or where you specifically authorized a disclosure, when you submit a written
request. The request must state the time period desired for the accounting, which must be less than a 6-year period and
starting after April 14, 2003. You may receive the list in paper or electronic form. The first disclosure list request in a 12-month
period is free; other requests will be charged according to our cost of producing the list. We will inform you of the cost before
you incur any costs.
Right to Obtain a Copy of this Notice
You may obtain a paper copy of this notice from the Texas (local) section of US Family Health Plan website at
Complaints
If you are concerned that your privacy rights may have been violated, or you disagree with a decision, we made about access
to your records, you may contact our Privacy Office (listed below). You may also contact our CHRISTUS Health Integrity
Line, available 24-hours, at 1-888-728-8383. Finally, you may send a written complaint to the U.S. Department of Health and
Human Services Office of Civil Rights. Our Privacy Officer can provide you the address. Under no circumstance will you be
penalized or retaliated against for filing a complaint.
Contact Information
You may contact your US Family Health Plan Privacy Officer for further information about the complaint process, or for
further explanation of this document.
Privacy Office Contact Information:
919 Hidden Ridge
Irving, TX 75016
1-800-678-7347
This notice is effective in its entirety as of April 14, 2003.
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TEXAS STATUTORY DURABLE POWER OF ATTORNEY
STATUTORY DURABLE POWER OF ATTORNEY
NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. THEY ARE
EXPLAINED IN THE DURABLE POWER OF ATTORNEY ACT, CHAPTER XII, TEXAS PROBATE CODE.
IF YOU HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL ADVICE. THIS
DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL AND OTHER HEALTH-CARE
DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO.
I, (insert your name and address), appoint (insert the name and address of the
person appointed) as my agent (attorney-in-fact) to act for me in any lawful way with respect to all of the following powers
except for a power that I have crossed out below.
CROSS OUT EACH POWER WITHHELD.
Real property transactions
Tangible personal property transactions
Stock and bond transactions
Commodity and option transactions
Banking and other financial institution transactions
Business operating transactions
Insurance and annuity transactions
Estate, trust, and other beneficiary transactions
Claims and litigation
Personal and family maintenance
Benefits from social security, Medicare, Medicaid, or other governmental programs or civil or military service
Retirement plan transactions
Tax matters
IF NO POWER LISTED ABOVE IS CROSSED OUT, THIS DOCUMENT SHALL BE CONSTRUED AND
INTERPRETED AS A GENERAL POWER OF ATTORNEY AND MY AGENT (ATTORNEY IN FACT) SHALL
HAVE THE POWER AND AUTHORITY TO PERFORM OR UNDERTAKE ANY ACTION I COULD PERFORM
OR UNDERTAKE IF I WERE PERSONALLY PRESENT.
57
SPECIAL INSTRUCTIONS:
Special instructions applicable to gifts (initial in front of the following sentence to have it apply):
I grant my agent (attorney in fact) the power to apply my property to make gifts, except that the amount of a gift to an
individual may not exceed the amount of annual exclusions allowed from the federal gift tax for the calendar year of the gift.
ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS LIMITING OR EXTENDING
THE POWERS GRANTED TO YOUR AGENT.
UNLESS YOU DIRECT OTHERWISE ABOVE, THIS POWER OF ATTORNEY IS EFFECTIVE
IMMEDIATELY AND WILL CONTINUE UNTIL IT IS REVOKED.
CHOOSE ONE OF THE FOLLOWING ALTERNATIVES BY CROSSING OUT THE ALTERNATIVE
NOT CHOSEN:
(A) This power of attorney is not affected by my subsequent disability or incapacity.
(B) This power of attorney becomes effective upon my disability or incapacity.
YOU SHOULD CHOOSE ALTERNATIVE (A) IF THIS POWER OF ATTORNEY IS TO BECOME
EFFECTIVE ON THE DATE IT IS EXECUTED.
IF NEITHER (A) NOR (B) IS CROSSED OUT, IT WILL BE ASSUMED THAT YOU CHOSE ALTERNATIVE (A).
58
If Alternative (B) is chosen and a definition of my disability or incapacity is not contained in this power of attorney,
I shall be considered disabled or incapacitated for purposes of this power of attorney if a physician certifies in writing
at a date later than the date this power of attorney is executed that, based on the physician’s medical examination of me,
I am mentally incapable of managing my financial affairs. I authorize the physician who examines me for this purpose to
disclose my physical or behavioral condition to another person for purposes of this power of attorney. A third party who
accepts this power of attorney is fully protected from any action taken under this power of attorney that is based on the
determination made by a physician of my disability or incapacity.
I agree that any third party who receives a copy of this document may act under it. Revocation of the durable power of
attorney is not effective as to a third party until the third party receives actual notice of the revocation. I agree to indemnify
the third party for any claims that arise against the third party because of reliance on this power of attorney.
If any agent named by me dies, becomes legally disabled, resigns, or refuses to act, I name the following (each to act alone
.
and successively, in the order named) as successor(s) to that agent: Signed this day of , 20
(your signature)
State of County of This document was acknowledged before me on (date)
by (name of principal)
(signature of notarial officer)
(Seal, if any, of notary) (printed name)
My commission expires: THE ATTORNEY IN FACT OR AGENT, BY ACCEPTING OR ACTING UNDER THE APPOINTMENT,
ASSUMES THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT.
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TEXAS STATUTORY ADVANCE MEDICAL DIRECTIVE
DIRECTIVE TO PHYSICIANS AND FAMILY OR SURROGATES
Instructions for completing this document:
This is an important legal document known as an Advance Directive. It is designed to help you communicate your wishes
about medical treatment at some time in the future when you are unable to make your wishes known because of illness or
injury. These wishes are usually based on personal values. In particular, you may want to consider what burdens or hardships
of treatment you would be willing to accept for a particular amount of benefit obtained if you were seriously ill.
You are encouraged to discuss your values and wishes with your family or chosen spokesperson, as well as your physician.
Your physician, other health care provider, or medical institution may provide you with various resources to assist you in
completing your advance directive. Brief definitions are listed below and may aid you in your discussions and advance
planning. Initial the treatment choices that best reflect your personal preferences. Provide a copy of your directive to your
physician, usual hospital, and family or spokesperson. Consider a periodic review of this document. By periodic review, you
can best assure that the directive reflects your preferences.
In addition to this advance directive, Texas law provides for two other types of directives that can be important during a
serious illness. These are the Medical Power of Attorney and the Out-of-Hospital
Do-Not-Resuscitate Order. You may wish to discuss these with your physician, family, hospital representative, or other
advisers. You may also wish to complete a directive related to the donation of organs and tissues.
DIRECTIVE
I, , recognize that the best health care is based upon a partnership of trust and communication with
my physician. My physician and I will make health care decisions together as long as I am of sound mind and able to make my
wishes known. If there comes a time that I am unable to make medical decisions about myself because of illness or injury, I
direct that the following treatment preferences be honored:
If, in the judgment of my physician, I am suffering with a terminal condition from which I am expected to die within six
months, even with available life-sustaining treatment provided in accordance with prevailing standards of medical care:
I request that all treatments other than those needed to keep me comfortable be discontinued or
withheld and my physician allow me to die as gently as possible; OR
I request that I be kept alive in this terminal condition using available life-sustaining
treatment. (THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)
61
If, in the judgment of my physician, I am suffering with an irreversible condition so that I cannot care for myself or make
decisions for myself and am expected to die without life-sustaining treatment provided in accordance with prevailing
standards of care:
I request that all treatments other than those needed to keep me comfortable be discontinued or
withheld and my physician allow me to die as gently as possible; OR
I request that I be kept alive in this irreversible condition using available life-sustaining treatment.
(THIS SELECTION DOES NOT APPLY TO HOSPICE CARE.)
Additional requests: (After discussion with your physician, you may wish to consider listing particular treatments in this space
that you do or do not want in specific circumstances, such as artificial nutrition and fluids, intravenous antibiotics, etc. Be sure
to state whether you do or do not want the particular treatment.)
After signing this directive, if my representative or I elect hospice care, I understand and agree that only those treatments
needed to keep me comfortable would be provided and I would not be given available life-sustaining treatments.
If I do not have a Medical Power of Attorney, and I am unable to make my wishes known, I designate the following person(s)
to make treatment decisions with my physician compatible with my personal values:
1. 2. (If a Medical Power of Attorney has been executed, then an agent already has been named and you should not list additional
names in this document.)
If the above persons are not available, or if I have not designated a spokesperson, I understand that a spokesperson will be
chosen for me following standards specified in the laws of Texas. If, in the judgment of my physician, my death is imminent
within minutes to hours, even with the use of all available medical treatment provided within the prevailing standard of care,
I acknowledge that all treatments may be withheld or removed except those needed to maintain my comfort. I understand
that under Texas law this directive has no effect if I have been diagnosed as pregnant. This directive will remain in effect until I
revoke it. No other person may do so.
Signed Date 62
City, County, State of Residence Two competent adult witnesses must sign below, acknowledging the signature of the declarant. The witness designated as
Witness 1 may not be a person designated to make a treatment decision for the patient and may not be related to the patient
by blood or marriage. This witness may not be entitled to any part of the estate and may not have a claim against the estate of
the patient. This witness may not be the attending physician or an employee of the attending physician. If this witness is an
employee of a health care facility in which the patient is being cared for, this witness may not be involved in providing direct
patient care to the patient. This witness may not be an officer, director, partner, or business office employee of a health care
facility in which the patient is being cared for or of any parent organization of the health care facility.
Witness 1 Witness 2 Definitions:
“Artificial nutrition and hydration” means the provision of nutrients or fluids by a tube inserted in a vein, under the skin in
the subcutaneous tissues, or in the stomach (gastrointestinal tract).
“Irreversible condition” means a condition, injury, or illness:
(1) that may be treated, but is never cured or eliminated;
(2) that leaves a person unable to care for or make decisions for the person’s own self; and
(3) that, without life-sustaining treatment provided in accordance with the prevailing standard of medical care, is fatal.
Explanation: Many serious illnesses such as cancer, failure of major organs (kidney, heart, liver, or lung), and serious brain
disease such as Alzheimer’s dementia may be considered irreversible early on. There is no cure, but the patient may be kept
alive for prolonged periods of time if the patient receives life-sustaining treatments. Late in the course of the same illness,
the disease may be considered terminal when, even with treatment, the patient is expected to die. You may wish to consider
which burdens of treatment you would be willing to accept in an effort to achieve a particular outcome. This is a very personal
decision that you may wish to discuss with your physician, family, or other important persons in your life.
“Life-sustaining treatment” means treatment that, based on reasonable medical judgment, sustains the life of a patient and
without which the patient will die. The term includes both life-sustaining medications and artificial life support such as
mechanical breathing machines, kidney dialysis treatment, and artificial hydration and nutrition. The term does not include
the administration of pain management medication, the performance of a medical procedure necessary to provide comfort
care, or any other medical care provided to alleviate a patient’s pain.
“Terminal condition” means an incurable condition caused by injury, disease, or illness that according to reasonable medical
judgment will produce death within six months, even with available life-sustaining treatment provided in accordance with the
prevailing standard of medical care.
Explanation: Many serious illnesses may be considered irreversible early in the course of the illness, but they may not be
considered terminal until the disease is fairly advanced. In thinking about terminal illness and its treatment, you again may
wish to consider the relative benefits and burdens of treatment and discuss your wishes with your physician, family, or other
important persons in your life.
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67
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69
70
71
72
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GLOSSARY
Except as otherwise defined in this handbook, the terms listed, if used, will have the following meanings:
Accident - A sudden, unforeseen and unexpected event that results in bodily injury.
Acute - Having rapid onset of severe symptoms and a short course, not chronic.
Alcoholism or Drug Addiction Treatment Facility - A facility that provides treatment of alcoholism or drug addiction.
Allotment - Automatic monthly payment option deducted from military retirement pay.
Appeal - A formal written request by an appropriate appealing party (ex: a member or a participating provider or a
designated representative) to resolve a disputed question of fact.
Authorized Services - Services that are medically necessary, delivered in the proper setting, a TRICARE benefit, and are
approved by US Family Health Plan.
Balance-Billing - An attempt by a provider to collect payment(s) from a member for covered services. This does not
include applicable copay or cost-share amounts.
Calendar Year - One year beginning January 1 and ending December 31.
Case Management - A nursing process that involves the patient. This includes assessing, planning, coordinating,
monitoring and evaluating care for a patient. Case management is not restricted to catastrophic illnesses and injuries.
Catastrophic Cap - The maximum out-of-pocket expenses (i.e. copays, fees) members are required to pay each
government fiscal year (see Chapter 7, page 16).
Chronic - A medical condition lasting a long time or re-occuring, not acute. A medical condition that is not curable
but which may be controlled/stabilized through active medical treatment.
Copay/Cost Share - The fee you are required to pay for certain services (see copay section for a detailed copay
listing on page 16).
Custodial Care - (This is a non-covered TRICARE benefit). Treatment or services, regardless of who recommends
such treatment or services or where such treatment or services are provided that (a) can be rendered safely and reasonably
by a person who is not medically skilled, or (b) is or are designed mainly to help the patient with the activities of daily
living (i.e. providing food, clothing and shelter; personal hygiene services; observation and general monitoring; bowel
training or management).
75
GLOSSARY
Defense Enrollment Eligibility Reporting System (DEERS) - Currently transitioned to DOES (Defense Online Enrollment
System) - The nationwide computerized system which lists all active and retired military members and their dependents.
Active and retired service members are listed automatically, but they must enroll their eligible family members and report
any changes to dependent status (divorce, adoption, etc.). To report changes, call 1-800-538-9552.
Disease Management - A disease-specific approach to improving health care outcomes by providing disease-specific
education and services to members.
Eligible Beneficiary/Dependent - A Military Health System (MHS) beneficiary who meets the eligibility requirements
set forth by the Department of Defense (DoD).
Emergency - A medical, maternity or psychiatric event that would lead a “prudent layperson” to believe that a serious
medical condition existed or the absence of medical attention would result in a threat to his/her life, limb or sight and requires
immediate medical treatment or which manifests painful symptomatology requiring immediate palliative effort to relieve
suffering. This includes situations where a beneficiary presents with severe pain.
Note: Uncomplicated obstetric delivery after the 34th week is not considered an emergency. To obtain care during normal
labor after the 34th week, follow the directions provided by your US Family Health Plan obstetric provider. Some examples
of medical emergencies include heart attacks, strokes, severe bleeding, poisoning, loss of consciousness or respiration, and
convulsions. (Refer to the section Emergency Coverage on page 8 for further information).
End Stage Renal Disease (ESRD) - A reduction in kidney function to a chronic level at which the kidneys are unable to
maintain normal function.
Extended Care Health Option (ECHO) - ECHO is a supplemental program to the TRICARE Basic Program and
provides eligible active duty family members with an additional financial resource for an integrated set of services and
supplies designed to assist in the reduction of the disabling effects of the beneficiary’s qualifying condition.
Department of Defense (DoD) Fiscal Year - The Department of Defense (DoD) fiscal year is October 1 through September
30 as dictated by the Federal Government.
Grievance - A written complaint on a non-appealable issue, which deals primarily with a perceived failure of a network
provider or US Family Health Plan to furnish the level or quality of care expected by a member.
76
GLOSSARY
Hospital - An institution that:
1. provides medical care and treatment of sick and injured persons on an inpatient basis
2. is properly licensed or permitted legally to operate as such
3. has a physician on call at all times
4. has licensed registered nurses on duty 24 hours a day
5. maintains facilities for the diagnosis and treatment of illness and for major surgery
6. meets the required standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
The definition of a hospital, provided the facility is licensed in the state in which the facility operates and is operating
within the scope of its license, may also include:
• alcoholism or drug treatment facility
• psychiatric hospital
• ambulatory surgical facility
• freestanding birth center
In no event will the definition of hospital include an institution or any part of one that is a convalescent/extended
care facility, or any institution which is used primarily as a:
• rest facility
• nursing facility
• facility for the aged
• place for custodial care
Illness - Any physical or mental sickness or disease that manifests treatable symptoms and that requires treatment
by a physician.
Injury - Any bodily damage or hurt sustained that requires treatment by a physician.
Inpatient - A person treated in a hospital as a registered bed patient incurring a charge for room and board, upon
the order of a physician.
Inquiry - Requests for information or assistance made by or on behalf of a beneficiary, provider, the public or the government.
Written inquiries may be made in any format. Allowable charges, complaints, grievances and appeals
are excluded from this definition.
Managed Care Plan - A health care system where medically necessary care is managed and coordinated by a primary
care physician (PCP).
Medical Foods - Food, food substitutes or supplements, and vitamins consumed outside a hospital, except for home
parenteral nutrition therapy.
77
GLOSSARY
Medically Necessary - The frequency, extent and types of medical services or supplies which represent appropriate medical
care and that are generally accepted by qualified professionals to be reasonable and adequate for the diagnosis and treatment
of illness, injury, pregnancy and mental disorders or that are reasonable and adequate for well-baby care. (Source CFR 199.2)
The fact that a provider may prescribe, order, recommend, or approve a service or supply does not, in and of itself, make that
service medically necessary.
A service or supply will not be considered medically necessary if:
1. it is provided only as a convenience to the member
2. it is not appropriate treatment for the member’s diagnosis or symptoms
3. it exceeds (in scope, duration or intensity) the level of care which is needed to provide safe, adequate and
appropriate diagnosis or treatment
Medline Plus® - Medline Plus® a website developed and maintained by the U.S. National Library of Medicine (NLM) and the
National Institutes of Health (NIH). This site will provide health professionals and health plan members with information
on diseases and conditions, clinical trials, drugs, and the latest health information. The use of this site is not intended to be a
substitute for health care information provided by The Plan, but may be used as a resource to supplement The Plan’s health
care information. See the Medline Plus® site at medlineplus.gov
Outpatient Care - This level of care includes services, supplies and medicines provided and used at a hospital or other covered
facility under the direction of a physician to a person not admitted as an inpatient.
Person with Disability - An individual with a physical or mental impairment that substantially limits one or more of the
major life activities of such individual.
Physician - A legally qualified person acting within the scope of his or her license and holding the degree of Doctor of
Medicine (M.D.) or Doctor of Osteopathy (D.O.).
Plan - US Family Health Plan (USFHP).
Preventive Care Services - Periodic health screenings such as physicals, well-woman exams, mammograms, cholesterol
screenings and blood pressure checks that conform to the recommendations of the United States Preventative Task Force
(www.uspreventiveservicestaskforce.org).
Primary Care Physician (PCP) - The family practice, general practice, internal medicine, geriatric medicine or pediatrician
you choose to be your personal physician or your eligible family member’s personal physician. Your PCP manages and
coordinates all medically necessary health care.
Provider - A hospital or other institutional provider of medical care or services, a physician or other individual professional
provider, or other provider of services or supplies in accordance with the Combined Federal Register (Source 32 CFR 199).
78
GLOSSARY
Renal Failure - A reduction in kidney function, to a level that the kidneys are unable to maintain normal function.
Room and Board - Charges made by the hospital or other covered institution for the cost of the room, general nursing
care and other services routinely provided to all inpatients, not including special care units.
Semiprivate Charge - The charge made by a hospital for a room containing two or more beds. This does not include
the charge made by the hospital for special care units.
Service Area - The geographic area in which US Family Health Plan provides covered services to members. It is defined
by a Department of Defense (DoD) zip-code-specific area.
Special Care Units - A hospital unit that provides special equipment and highly skilled personnel for the care of critically
ill patients requiring immediate, constant and continuous attention.
This includes charges for intensive care, coronary care and acute care units of a hospital, but does not include care in a surgical
recovery or post-operative room. The unit must meet the required standards of the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) for special care units.
Specialist - A physician who practices in a particular area of medicine such as Cardiology, Dermatology or Urology.
Substance Abuse - Use or dependence on a drug or other chemical, leading to effects that are harmful to the physical or
mental health and welfare of self or others.
Third-Party Liability - The recovery of the reasonable value of care and treatment furnished or to be furnished by or for the
government to persons entitled to such care and treatment when such persons suffer injury or disease under circumstances
which create tort or contractual liability on third parties, including insurance companies, to pay damages.
TRICARE Young Adult (TYA) - A coverage option under USFHP for dependents of members. The dependent must be
under age 26, unmarried and not eligible for any other employer-sponsored health care coverage.
URAC - An independent, nonprofit organization committed to promoting health care quality through accreditation,
certification and other quality improvement activities.
Urgent Care - A condition which is not life threatening that requires care within several hours, and in all cases within 24
hours, after the onset of illness or injury. Examples of urgent care needs include sudden abdominal pain or an increase in
body temperature.
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NOTES
80

1-800-678-7347 • www.USFamilyHealthPlan.org

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