Type of Care |
Active Duty Family Member |
Retiree Family Member |
---|
TYA Prime |
TYA Select |
TYA Prime |
TYA Select |
Ambulance Services (Outpatient) |
$0 |
Network: $16
Non-Network: 20% |
$44 |
Network: $67
Non-Network: 25% |
Ambulatory Surgery |
$0 |
Network: $28
Non-Network: 20% |
$67 |
Network: $106
Non-Network: 25% |
Ancillary Services |
$0 |
Network: $0
Non-Network: 20% |
$0 |
Network: $0
Non-Network: 25% |
Durable Medical Equipment |
$0 |
Network: 10%
Non-Network: 20% |
20% |
Network: 20%
Non-Network: 25% |
Emergency Room |
$0 |
Network: $44
Non-Network: 20% |
$67 |
Network: $89
Non-Network: 25% |
Home Health Care |
$0 |
$0* |
$0* |
$0* |
Hospice Care |
$0 |
$0 |
$0 |
$0 |
Hospitalization
(Includes Mental Health) |
$0 |
Network: $67 per admission
Non-Network: 20% |
Network: $168 per admission
Non-Network: Lesser of $158 per admission |
Network: $196 per admission
Non-Network: 25% |
Laboratory and X-Rays |
$0 |
Network: $0
Non-Network: 20% |
$0 |
Network: $0
Non-Network: 25% |
Maternity Care (Delivery
Planned in an Inpatient Setting) |
$0 |
Network: $67
Non-Network: 20% |
Network: $168 per admission
Non-Network: Lesser of $158 per admission |
Network: $196
Non-Network: 25% |
Office Visits (Primary Care) |
$0 |
Network: $16
Non-Network: 20% |
$22 |
Network: $28
Non-Network: 25% |
Office Visits (Specialty Care) |
$0 |
Network: $28
Non-Network: 20% |
$33 |
Network: $44
Non-Network: 25% |
Outpatient Mental Health Visits |
$0 |
Network: $28
Non-Network: 20% |
$33 |
Network: $44
Non-Network: 25% |
Partial Hospitalization |
$0 |
Network: $28**
Non-Network: 20% |
$33 per day** |
Network: $44**
Non-Network: 25% |
Preventive Services
(Eye Examinations) |
$0 |
Network: $0
Non-Network: 20% |
$0 |
Not a covered benefit |
Preventive Services (All Other
Covered Services) |
$0 |
$0 |
$0 |
$0 |
Residential Treatment Center |
$0 |
Network: $28 per day
Non-Network: $56 per day |
$33 per day |
Network: $56 per day
Non-Network: Lesser of $336
per day or 20% of allowable charges |
Skilled Nursing Facilty |
$0 |
Network: $28 per day
Non-Network: $56 per day |
$33 per day |
Network: $56 per day
Non-Network: Lesser of $336
per day or 20% of allowable charges |
Urgent Care Services |
$0 |
Network: $22
Non-Network: 20% |
$33 |
Network: $44
Non-Network: 25% |