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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 10/1/2017.
Service Cost
Ambulance Services $20 per occurance
Ambulatory Surgery (Same Day) $25
Mental Health (Inpatient)

$11 per day ($25 minimum charge)

Mental Health (Partial Hospitalization)

$12 per visit

Mental Health (Outpatient)

$12 per visit

Clinical Preventive Services $0
DME, Prosthetic Devices, Medical Supplies 20% of the negotiated feeThe discounted rate network providers agree to accept for covered services.
Emergency Services $30 per visit
Home Health Care $0

Note: You may have separate costs for additional services when receiving home health care. For example, DME, drugs, vaccines, orthotics/prosthetics, and nutritional therapy, among others.
Hospice Care $0
Hospitalization (Inpatient Care) $11 per day ($25 minimum charge)
Immunizations $0
Laboratory and X-ray

Ancillary* services: $0
Other Radiology services: $12 per visit

Maternity (office visits and 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)

Urgent Care

$12 per visit
*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