Type of Care |
Active Duty Family Member |
Retiree Family Member |
---|
TYA Prime |
TYA Select |
TYA Prime |
TYA Select |
Ambulance Services -Outpatient (air) |
$0 |
20% |
$20 |
25% |
Ambulance Services -Outpatient (ground) |
$0 |
Network Provider: $18
Non-Network Provider: 20% |
$50 |
Network Provider: $75
Non-Network Provider: 25% |
Ambulatory Surgery |
$0 |
Network Provider: $31
Non-Network Provider: 20% |
$75 |
Network Provider: $119
Non-Network Provider: 25% |
Ancillary Services |
$0 |
Network Provider: $0
Non-Network Provider: 20% |
$0 |
Network Provider: $0
Non-Network Provider: 25% |
Durable Medical Equipment |
$0 |
Network Provider: 10%
Non-Network Provider: 20% |
20% |
Network Provider: 20%
Non-Network Provider: 25% |
Emergency Room |
$0 |
Network Provider: $50
Non-Network Provider: 20% |
$75 |
Network Provider: $100
Non-Network Provider: 25% |
Home Health Care |
$0 |
$0* |
$0* |
$0* |
Hospice Care |
$0 |
$0 |
$0 |
$0 |
Hospitalization
(Includes Mental Health) |
$0 |
Network Provider: $75 per admission
Non-Network Provider: 20% |
$188 per admission
|
Network Provider: $219 per admission
Non-Network Provider: 25% |
Laboratory and X-Rays |
$0 |
Network Provider: $0
Non-Network Provider: 20% |
$0 |
Network Provider: $0
Non-Network Provider: 25% |
Maternity Care (Delivery
Planned in an Inpatient Setting) |
$0 |
Network Provider: $75 per admission
Non-Network Provider: 20% |
$188 per admission
|
Network Provider: $219
Non-Network Provider: 25% |
Office Visits (Primary Care) |
$0 |
Network Provider: $18
Non-Network Provider: 20% |
$25 |
Network Provider: $31
Non-Network Provider: 25% |
Office Visits (Specialty Care) |
$0 |
Network Provider: $31
Non-Network Provider: 20% |
$37 |
Network Provider: $50
Non-Network Provider: 25% |
Outpatient Mental Health Visits |
$0 |
Network Provider: $31
Non-Network Provider: 20% |
$37 |
Network Provider: $50
Non-Network Provider: 25% |
Partial Hospitalization |
$0 |
Network Provider: $31**
Non-Network Provider: 20% |
$37 per day** |
Network Provider: $50**
Non-Network Provider: 25% |
Preventive Services
(Eye Examinations) |
$0 |
Network Provider: $0
Non-Network Provider: 20% |
$0 |
Not a covered benefit |
Preventive Services (All Other
Covered Services) |
$0 |
$0 |
$0 |
$0 |
Residential Treatment Center |
$0 |
Network Provider: $31 per day
Non-Network Provider: $62 per day |
$37 per day |
Network Provider: $62 per day
Non-Network Provider: Lesser of $377
per day or 20% of allowable charges |
Skilled Nursing Facilty |
$0 |
Network Provider: $31 per day
Non-Network Provider: $62 per day |
$37 per day |
Network Provider: $62 per day
Non-Network Provider: Lesser of $377
per day or 20% of allowable charges |
Urgent Care Services |
$0 |
Network Provider: $25
Non-Network Provider: 20% |
$37 |
Network Provider: $50
Non-Network Provider: 25% |