Overview of Medical Benefits

TRICARE Prime Benefits

Cost for Active-Duty Family Members
Cost for Retirees and their Family Members / Survivors

Premium Fees

$0

$289.08 individual / $578.16 family

Outpatient Services (subject to medical review)

Cost for Active-Duty Family Members
Cost for Retirees and their Family Members / Survivors

Office visits

$0

$20

Maternity care
(prenatal, postnatal)

$0

$30

Well-child care (birth to age 6)

$0

$0

Routine physical examinations6

$0

$0

X-ray and lab tests1

$0

$0

Ambulatory surgery
(same day)

All surgical procedures (regardless of where they are performed; excluding some venipuncture and fetal monitoring procedures) and birthing centers (prenatal care, outpatient delivery, and postnatal care)

$0

$60

Physical Therapy
(when medically necessary)

$0

$30

Cardiac Rehabilitation

$0

$30

Inpatient Services (subject to medical review)

Cost for Active-Duty Family Members
Cost for Retirees and their Family Members / Survivors

Hospitalization
(semi-private room and board)

$0

$150/admission

Physician services

$0

$0

General nursing services

$0

$0

Diagnostic tests including lab and X-ray

$0

$0

Operating room, anesthesia and supplies

$0

$0

Medically necessary supplies and services

$0

$0

Physical therapy (when medically necessary)

$0

$0

Mental Health Services (subject to medical review)

Cost for Active-Duty Family Members
Cost for Retirees and their Family Members / Survivors

Outpatient care individual

$0

$30/visit

Outpatient group / family therapy

$0

$30/visit

Partial hospitalization mental health

$0

$30/visit

Inpatient hospital psychiatric care

$0

$150/admission

Substance Abuse Treatment (subject to medical review)

Cost for Active-Duty Family Members
Cost for Retirees and their Family Members / Survivors

Outpatient care individual

$0

$30/visit

Outpatient group / family therapy

$0

$30/visit

Inpatient services

$0

$150/admission

Inpatient rehabilitation / Partial hospitalization program

$0

$30/day

Other Service (subject to medical review)

Cost for Active-Duty Family Members
Cost for Retirees and their Family Members / Survivors

Ambulance services5 (when medically necessary)

$0

$40/occurrence

Dental Care - basic preventive

Reduced fees

Reduced fees

Durable medical equipment

$0

20%

Emergency room services2 (including out of the area)

$0

$60

Urgent care center

$0

$30

Routine eye examination (1 per year)

$0

$0

Radiation/chemotherapy office visits

$0

$30

Prescription drug co-pays3 (Rite Aid retail)
(up to a 30-day supply)

$11 generic
$28 brand name
$53 non-preferred brand name

$11 generic
$28 brand name
$53 non-preferred brand name

Prescription drug co-pays3 (Home delivery only)
(up to a 90-day supply)

$7 generic
$24 brand name
$53 non-preferred brand name

$7 generic
$24 brand name
$53 non-preferred brand name

Skilled nursing facility care

$0

$30/day

Home health care (part-time skilled nursing care)

$0

$0

Out of area (emergency services only)

$0

$60

Catastrophic cap7

$1,000/enrollment year

$3,000/enrollment year

1
If lab services are provided on the same day as the office visit and a co-pay is collected for the visit, no additional co-pay will be collected. No co-pay will be collected when services are billed and provided as clinical preventive services. Exceptions: Co-pay may be required for certain radiation oncology, vascular and pulmonary procedures and studies. Contact Customer Service for details.
2
Unless you are admitted to the hospital, in which case only the inpatient co-payment applies.
3
Prescription drug availability is limited to drugs prescribed by a Plan provider and covered as a Plan benefit. Availability of non-emergency prescriptions when out of the area is also limited. Over-the-counter medications and supplies are not covered. Retail vendor for prescriptions is Rite Aid Pharmacy.
4
Outpatient treatment following the initial intake evaluation and testing is limited to a maximum of 36 sessions per cardiac event.
5
Upon arrival of the ambulance and member refuses transport, the member is liable/responsible for services rendered.
6
Routine Physical Examinations – while there is no co-pay for a Routine Physical; an office visit co-pay may be assessed if other procedures (not considered routine) are conducted during the examination.
7
Annual premiums do not apply toward the catastrophic cap.

Pharmacy & Prescription Drug Benefits

Walgreens will acquire a large number of Rite Aid locations throughout the country. Johns Hopkins has partnered with Walgreens to ensure that USFHP members can continue to fill their prescriptions at Rite Aid pharmacies that have converted to Walgreens. This change is only applicable to Rite Aid pharmacies that have converted to Walgreens and not applicable to other Walgreens pharmacies. Members will be advised in due course of future changes to the pharmacy network. You may contact our customer service unit at 410-424-4528 or 1-800-808-7347 if you need assistance identifying a network pharmacy.

Find a network pharmacy near you

Filling your prescription

You may obtain your prescriptions at any of the Rite Aid pharmacies nationwide or through home delivery. For the location of a Rite Aid pharmacy near you, call 1-800-748-3243 or visit www.riteaid.com.



Note: You may not obtain prescriptions from a military treatment facility while enrolled in the USFHP. Prescriptions that originated at a military treatment facility may not be transferable to Rite Aid pharmacies.

Any prescriptions filled outside the Rite Aid network in a non-emergent situation will be reviewed for medical necessity and if approved, will be reimbursed at the USFHP contracted rate less applicable co-payment.

Home delivery

Home delivery is available to Maryland and Northern Virginia residents for up to a 90-day supply of approved medications through Rite Aid Pharmacy at Remington. Home delivery is best suited for medications you take on a regular basis. To obtain your prescription through home delivery, complete the mail order form and send it in with your new prescription. If you need a refill, please fill out and send in the mail order form along with your prescription number, plus a check or credit card number for your copayment. The mail order form may also be securely emailed to you through your HealthLINK@Hopkins account. Your prescription order will be processed promptly and most orders are received within two weeks. To ensure you receive a refill before your current supply runs out, reorder at least two weeks before you need your refill.

Rite Aid Pharmacy
2700 Remington Ave.
Baltimore, MD 21211
Phone: 410-235-2128

Fax: 410-889-1609

Retail pharmacy pick-up

Fill and pick up your prescriptions at any of our network pharmacies nationwide without having to submit a claim. Through our retail pharmacy network, you can fill a 30-day supply of your everyday medications, or a 90-day supply of medications for a chronic condition, for the same copay as home delivery. To fill a prescription, present your Johns Hopkins USFHP Member ID card to the pharmacist with your prescription. You will be required to make a copay at the time of service. The copay levels are printed on your ID card. Your ID card also contains important information to allow the pharmacy to process your claim correctly.

Specialty medications

Specialty medications are usually high-cost, self-administered, injectable, oral, or infused drugs that treat serious chronic conditions. These drugs typically require special storage and handling, and may not be readily available at your local pharmacy. Specialty medications may also have side effects that require pharmacist and/or nurse monitoring. Many specialty medications (oral and injectable) are available through the retail pharmacy network.  However, some medications may not be available at all retail locations because the medication’s manufacturer limits the medication to specific pharmacies.  If your physician submits a request for use of a restricted distribution drug and we approve it, we will forward the request to a contracted specialty pharmacy. The specialty pharmacy will coordinate delivery of the medication to patient’s home or physician office.

Formulary

Johns Hopkins USFHP utilizes the TRICARE pharmacy formulary. The formulary lists all of the prescription drugs that are covered under the TRICARE benefit. It is a tiered, open formulary, and includes generic drugs (Tier 1), preferred brand drugs (Tier 2), and non-preferred brand drugs (Tier 3). Each of these tiers represents a cost share that USFHP members are responsible for paying.

Use the TRICARE formulary search tool to see whether a specific drug is covered and its cost share.

You can also find information about medications, including how to take them, possible side effects, and drug interactions.

Formulary changes

The formulary is updated on a regular basis to include tier changes and utilization (UM) requirements. Review the latest formulary changes.

Prior authorization

Some medications require prior authorization from our plan before they can be dispensed by your pharmacist. This helps us ensure that the medication your doctor is prescribing you is medically necessary.

For a list of drugs that require prior authorization, refer to the TRICARE Prior Authorization page.

To initiate a prior authorization, your doctor must complete and fax the prior authorization form to the Johns Hopkins HealthCare Pharmacy department at 410-424-4607.

Step therapy

Step therapy is a process where we look for ways to provide our members the most cost-effective medication that is safe and clinically effective for their condition. The preferred prescribed medication is often a generic version that offers the best overall value in terms of safety, effectiveness, and cost. Non-preferred drugs are only prescribed if the preferred medication is ineffective or poorly tolerated.

Drugs subject to step therapy will be approved for first-time users only after they have tried one of the preferred agents as covered in the TRICARE formulary. When medically necessary, your doctor can request an exception to the step therapy requirement by submitting a prior authorization request.

Quantity limits

Quantity limits are established for certain drugs to ensure the medication is being used correctly. If your medical condition warrants a larger quantity of your medication than the listed quantity limit, your doctor should submit a prior authorization request.

Medical necessity

You can get non-formulary drugs at a network pharmacy or through home delivery at the regular formulary copay if medical necessity, criteria established by the Department of Defense Pharmaceutical & Therapy (DoD P&T) Committee, is met. Your doctor can assert medical necessity by submitting a prior authorization request.

Generic substitution

The DoD’s policy on generic drugs requires the pharmacy to substitute generic medications for brand-name medications when a generic equivalent is available. Brand-name drugs with a generic equivalent may be given only if your physician submits a prior authorization request and approval is granted by USFHP. In those cases, you will pay the brand name copayment. If you insist on having a prescription filled with a brand name drug when a generic equivalent is available, and medical necessity for the brand name drug has not been established, you will be responsible for the entire cost of the prescription.

Although generic drugs are chemically identical to their branded counterparts and are held to the same FDA standards for safety and performance as brand-name drugs, they sell for 30-75 percent less. You can save money on your co-payment by choosing generic drugs when applicable. Additional information on generic drugs is available on the FDA website.

Other covered medications

Our pharmacy program provides outpatient coverage to members for medications that are approved for marketing by the U.S. Food and Drug Administration (FDA) and that generally require prescriptions. Other covered medications include:

  • Compounded medications of which at least one ingredient is a legend drug
  • Insulin
  • Insulin syringes and needles
  • Smoking cessation products at no out of pocket cost (maximum of 2 quit attempts per year)
  • Glucose test strips
  • Lancets

Non-covered medications

Prescription medications that are used to treat conditions not currently covered by USFHP by statute or regulation are excluded from the pharmacy benefit.
Excluded medications include:

  • Drugs prescribed for cosmetic purposes
  • Fluoride preparations
  • Food supplements
  • Homeopathic and herbal preparations
  • Multivitamins
  • Over-the-counter products (except insulin, diabetic supplies, and smoking cessation products)
  • Weight reduction products
  • Two free dental cleanings each year
  • Discount on dental services at network dentists* in Maryland, Washington, D.C., Delaware, Pennsylvania, and West Virginia
    • No premiums
    • No paperwork or claims to fill out
    • No deductibles or maximums
    • No need to select a primary dental office
    • No referrals required to see a specialist

*Note: the discount on dental services is not available at network dentists in Virginia at this time.

Find a dentist near you

For more information, visit the United Concordia “Clients’ Corner” page.

  • One routine eye exam per year, which includes refractions and written lens prescriptions, from a designated plan provider

Call USFHP Customer Service at 1-800-808-7347 or search for an eye care facility near you.

Note: diagnosis and treatment of eye disease is covered in the same manner as any other medical specialty care and requires a referral from your primary care provider (PCP).

Non-covered services:

  • Corrective lenses, frames, contact lenses and contact lens fittings are not covered.
  • Corrective vision surgery is not covered [e.g., laser-assisted in situ keratomileusis (LASIK), radial keratotomy, photo refractive keratectomy (PRK), etc.].

Vision discounts:

  • 20% discount on any pair of lenses and frames
  • 5% discount on contact lenses

Discounts apply at all Wilmer Optical Shops and Superior Vision (formerly Block Vision) locations.

LASIK at Wilmer

For more information or to schedule an appointment, call one of our laser vision centers.

Green Spring Station:  410-583-2800
Bel Air: 410-893-0480

Infertility Treatment Services

We’ve partnered with the Johns Hopkins University Department of Gynecology & Obstetrics, Division of Reproductive Endocrinology & Infertility to offer our members a comprehensive program of assisted reproductive technologies for the treatment of infertility.

  • Diagnostic services are covered
  • Discount is offered for all IVF (in vitro fertilization) and IUI (intrauterine insemination)

If you are interested in IVF or IUI procedures, you will need to get a referral from your PCP or OB provider.  An initial appointment can be made in approximately 10 days from referral by calling: 410-616-7140.

Elective Cosmetic Surgery
  • $500 discount on any procedure including anti-aging procedures, such as face lifts and rhinoplasty or nose jobs
  • 15% discount on injectables including Botox

Discounts are offered by Dr. Byrne, Dr. Lisa Ishii, and Dr. Kofi Boahene at the Center for Facial Plastic and Reconstructive Surgery at Johns Hopkins.

Note: discounts apply to physician fee only. Hospital fees are not discounted due to Maryland regulations.

To request an appointment or to get more information about the Johns Hopkins Center for Facial Plastic and Reconstructive Surgery at Green Spring Station, call 410-955-4985.

ECHO Program

TRICARE offers a special program, the Extended Care Health Option (ECHO), to provide financial assistance for qualifying military beneficiaries who have been diagnosed with moderate or severe intellectual disability, a serious physical disability, or an extraordinary physical or psychological condition.

Some examples of qualifying conditions include:

  • Diagnosis of a neuromuscular developmental condition or other condition in an infant or toddler expected to precede a diagnosis of moderate or severe mental retardation or serious physical disability
  • Extraordinary physical or psychological condition causing the beneficiary to be homebound
  • Moderate or severe mental retardation
  • Multiple disabilities (may qualify if there are two or more disabilities affecting separate body systems)
  • Serious physical disability

The ECHO program’s coverage includes:

  • Assistive services (e.g., those from a qualified interpreter or translator)
  • Durable equipment, including adaptation and maintenance
  • Expanded in-home medical services through TRICARE ECHO Home Health Care (EHHC)
  • Medical and rehabilitative services
  • In-home respite care services (can only be used in a month when at least one other ECHO benefit is being received):
    • ECHO respite care—up to 16 hours per month (limited to the 50 United States, the District of Columbia, Puerto Rico, the U.S. Virgin Islands and Guam)
    • EHHC respite care—up to eight hours per day, five days per week for those who qualify Note: The EHHC benefit cap is equivalent to what TRICARE would reimburse if the beneficiary was in a skilled nursing facility
  • Training to use assistive technology devices
  • Institutional care when a residential environment is required
  • Special education (which can include applied behavioral analysis)
  • Transportation under certain limited circumstances (includes the cost of a medical attendant when needed to safely transport the beneficiary)

ECHO benefits, services, and supplies are not available through the basic Johns Hopkins USFHP. All ECHO services require pre-authorization through Johns Hopkins USFHP Care Management.

To enroll in the ECHO program, you must currently be a member of Johns Hopkins USFHP, be enrolled in the Exceptional Family Member Program (EFMP) of their branch of service, and provide medical documentation that a qualifying condition exists. USFHP will grant provisional ECHO enrollment (for 90 days) while the sponsor completes the EFMP forms.  Upon receipt of the application and documentation, members will receive a decision letter with their eligibility status.

  • For general questions, potential ECHO enrollees or family members may call Johns Hopkins USFHP customer service at 410-424-4528 or 1-800-808-7347. We also have a dedicated ECHO Care Coordinator who can answer more detailed questions regarding the eligibility and enrollment process.