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US Family Health Plan Copayments

  • Active duty family members pay nothing out-of-pocket for any type of care.
  • All others pay the following copayments:

These costs are effective 10/1/2014.
Service Cost
Ambulance Services $20 per occurance
Ambulatory Surgery (Same Day) $25
Behavioral Health (Inpatient) $40 per day
Behavioral Health (Outpatient) Individual: $25 / Group: $17
Clinical Preventive Services $0
DME, Prosthetic Devices, Medical Supplies 20% of the negotiated fee
Emergency Services $30 per visit
Home Health Care $0
Hospice Care $0
Hospitalization (Inpatient Care) $11 per day
($25 minimum charge)
Immunizations $0
Laboratory & X-ray $0 for ancillary services* / $12 per visit for other radiology services
Maternity (office visits & hospitalization for delivery planned in a hospital in an inpatient setting) $11 per day
($25 minimum charge)
Note: this is one global fee for all of the maternity care and delivery.
Maternity (office visits for delivery planning in a TRICARE-authorized birthing center) $25 per visit
Maternity (office visits for delivery planned at home or other setting) $12 per visit
Newborn Care $11 per day
($25 minimum charge)
Outpatient Visit $12 per visit
Skilled Nursing (Inpatient) $11 per day
($25 minimum charge)
*Ancillary services include:
  • Diagnostic radiology and ultrasound
  • Diagnostic nuclear medicine
  • Pathology and laboratory services
  • Cardiovascular studies
  • Venipuncture
  • Collection of blood samples
  • Fetal monitoring

Last Updated 1/27/2015