Johns Hopkins US Family Health Plan
2024 Member Handbook
Quick Reference
Medical Emergencies
For life-threatening emergency treatment..................................Call 911
To arrange for emergency or urgent care
In area ............................................................. Call your PCM
Out of area ......................................................... Call your PCM
Out of country .............. Notify Customer Service Department within 7 days of return
Member Information and Assistance
Johns Hopkins US Family Health Plan
7231 Parkway Drive, Suite 100, Hanover, MD 21076 ...........800-80-USFHP (800-808-7347)
Benefits Questions
Billing................... 410-424-4835 or 888-717-8282 or [email protected]
Coordination of Benefits...............................................410-424-4716
Discounted Dental Plan:
Concordia Advantage Network ........................................... 800-332-0366
Care Management .................................................... 800-557-6916
Utilization Management ............................... 410-424-4480 or 800-261-2421
Enrollment Department 410-424-4528 or 800-808-7347 or [email protected]
Pharmacy Services ................................................... 800-808-7347
Mail-order Pharmacy in Maryland ........................................ 410-235-2128
Mail-order pharmacy outside of Maryland.................................. 800-345-1985
Website ..................................................... www.hopkinsusfhp.org
After-Hours Services
Call our Nurse Line – Answers for your health questions 24 hours a day, at 866-444-3008. Or call your
Primary Care Provider’s after-hours service.
Virtual On Demand – Johns Hopkins OnDemand Virtual Care (weekdays from 6 p.m. to 8 a.m. and on
the weekends). Visit hopkinsmedicine.org/ondemand or download the app.
Behavioral Health / Substance Abuse Services
Johns Hopkins Health Plans-Behavioral Health Utilization Department ........... 410-424-4830
Out of area ............................................................ 888-281-3186
Defense Enrollment Eligibility Reporting System (DEERS)
Defense Manpower Data Center Support Office
Attention: COA, 400 Gigling Road, Seaside, CA 93955-6771
Toll Free ..............................................800-538-9552 FAX: 800-336-4416
Website ..................................................... www.tricare.mil/DEERS
Johns Hopkins USFHP ..............................1
Long History with the Uniformed Services .............2
How the Plan Works ...............................2
Getting Started ....................................3
Member ID Card Overview ..........................6
The Role of Your Primary Care Manager ...............7
If You Need Specialty Care .............................. 7
If You Are Admitted to a Hospital .......................7
Choosing Your Primary Care Manager .................... 7
Hospital Services ...................................... 7
Accessibility of Services .............................8
Emergency Care ................................. 8
After-Hours Service .............................. 8
NurseLine ............................................8
Nurse Chat Line .......................................8
Virtual OnDemand .....................................8
Medline Plus ..........................................9
Non-Emergency Urgent Care ...................... 9
In The Plan Area .......................................9
Outside The Plan Area .................................9
Emergency or Urgent Care Out of the Country or at Sea .... 9
Emergency Prescriptions ...............................10
Benefits ....................................... 10
Covered Benefits .....................................10
Point of Service (POS) Option .......................... 10
Catastrophic Loss Protection Benefit (Catastrophic Cap) ...10
Plan Benefits Chart ............................11-12
Footnotes to Plan Benefits Chart ........................12
Limitations to Benefits .................................12
Examples of Specific Exclusions and Limitations ............12
Other Services ................................13-15
Ambulance Service ...................................13
Dental Care .........................................13
Vision Care .........................................13
Diagnostic Services ...................................14
Hospice Care ........................................14
Behavioral Health .....................................14
National Cancer Institute Clinical Trials ..................15
Durable Medical Equipment ............................15
ECHO (Extended Care Health Option) ................... 15
Evaluation of New Technology, Drugs, and Benefits ....16
Care Management .............................16-17
Preventive Care ......................................17
Transitional Care ...................................... 17
Complex Care .......................................17
Behavioral Health ....................................17
Maternal/Child Health .................................17
How to Self-Refer ....................................17
Health Education .....................................18
Utilization Management ...........................18
Pharmacy and Prescription Drug Service ..........19-23
Retail Pharmacy Network ..............................19
Home Delivery/Mail Order Pharmacy ....................19
Vaccine Administration at Walgreens Pharmacies ...........20
Formulary and Co-Payments ............................20
Covered Medications .................................20
Non-Covered Medications .............................21
Formulary ...........................................21
Generic Drug Policy ..................................21
Quantity Limits .......................................21
Prior Authorization ...................................22
Step Therapy .........................................22
Medical Necessity for Non-Formulary Medications .........22
Out of Network Claims/Reimbursement .................. 22
Online Coordination of Benefits .........................22
Specialty Medications ..................................23
Drug Information .....................................23
Prescription Drug Recalls ............................... 23
Skilled Nursing Care ..............................23
Inpatient Skilled Nursing Care ...........................23
Home Care ..........................................23
Enrollment in the Plan .........................24-26
Eligibility .............................................24
Beneficiary Web Enrollment (BWE) .....................24
Military Treatment Facility Privileges ......................24
Changes Affecting Eligibility ............................24
Enrollment Fees ......................................25
Moving with TRICARE Prime ...........................26
Split Enrollment ......................................26
Disenrollment .......................................26
Other Insurance .................................27
Coordination of Benefits ..............................27
Third-Party Liability and Work-Related Injury ..............27
Insurance Changes ....................................27
Marketing and Enrollment Limitations ...................27
Customer Service ................................27
Claims and Member Reimbursements ................28
Grievances, Complaints and Appeals .....................28
Members’ Rights and Responsibilities .............29-30
Privacy and Confidentiality ..............................30
Fraud and Abuse .....................................30
Definition of Terms ............................31-32
Table of Contents
1
Johns Hopkins US Family Health Plan
New to the Johns Hopkins
US Family Health Plan?
You may have questions and concerns regarding
various aspects of your coverage and how
the Plan works. Our highly trained customer
service representatives are ready to answer
your questions, help you locate a primary
care provider or a specialist, or provide other
assistance you might need. We are available
Monday through Friday
8:00 a.m. to 4:30 p.m.
Telephone:
410-424-4528 or toll free, 800-808-7347
E-mail:
usfhpcustomerser[email protected]
Read Your Handbook
Carefully
The
Member Handbook
is a summary of
eligibility requirements, medical coverage,
co-payments, definition of terms, exclusions, and
other provisions of the USFHP.
Please note: This handbook is only as current
as the date of publication and is subject to
change without notice. The
Member Handbook
is also available on our website and should be
used as an additional resource. The handbook
is located on the home page at the following
address:
hopkinsusfhp.org
Updates are also provided to members by
individual mailings or in
The Patriot Life
, the
quarterly member newsletter.
Welcome
to the Johns Hopkins US Family Health Plan for retirees and their family members and active-
duty family members of the uniformed services. This Member Handbook provides you with the
information you will need to get the most from the Plan and to ensure that you know the best way to
obtain the services and benefits.
2024
Member Handbook
Johns Hopkins US Family Health Plan
2
Johns Hopkins US Family Health Plan
Johns Hopkins USFHP
Johns Hopkins USFHP or the Plan is a Department
of Defense (DoD) sponsored program that delivers
TRICARE Prime
®
benefits to retirees and their family
members, active-duty family members and survivors
of the uniformed services, including the Army, Navy,
Marine Corps, Air Force, Space Force, Coast Guard,
Public Health Service, and the National Oceanic and
Atmospheric Administration (NOAA).
Johns Hopkins USFHP’s extensive provider network
offers many primary care options throughout its service
area. In Maryland and the Washington D.C. area, Johns
Hopkins Community Physicians is the largest primary
care provider group, featuring more than 400 physicians
and other health care professionals. JHCP offers the
full range of primary care services and some specialty
services. Some locations also offer additional onsite
services, including pharmacy, labs, X-ray, ophthalmology
and optometry. For all USFHP members, specialty care
is available by referral to specialists in the Johns Hopkins
Health System or the Plan’s extensive network.
Long History with the
Uniformed Services
Johns Hopkins’ history of providing health care to the
military began when seven U.S. Public Health Service
Hospitals were transferred to private health care entities
with the stipulation that they continue to care for the
uniformed services beneficiaries through their federal
designation as Uniformed Services Treatment Facilities.
Following the closure of the Baltimore U.S. Public Health
Service Hospital, the Wyman Park Health System was
established (1982) and was subsequently acquired by the
Johns Hopkins Health System (1986).
In 1993 the DoD reorganized these facilities into the
Uniformed Services Family Health Plan. It was the first
DoD-sponsored, full-risk, managed health care plan.
The USFHP has been serving military families for more
than 40 years and is a part of the military health system
known as TRICARE.
How the Plan Works
Johns Hopkins USFHP is a managed care plan, designed
to provide comprehensive TRICARE Prime medical
benefits to enrolled individuals at a low out-of-pocket
cost. A managed care plan is an organized system
of health care delivery that relies on a primary care
manager (PCM)—a pediatrician, family practitioner or
internist—to arrange for all of your health care needs
with specific providers and hospitals. Payment for these
services is handled by the Plan. Full coverage for covered
benefits is available only from Plan providers except
during a medical emergency. There are no claim forms
when Plan-approved providers are used.
Because the Plan provides or arranges for your care
and pays the cost of all authorized services (less any
applicable co-payments/cost-shares), every effort will be
made to provide efficient and effective delivery of health
care services.
3
Johns Hopkins US Family Health Plan
Get Started With USFHP
Take these three steps to get off to a great start with
USFHP.
1. Sign up for your member portal
HealthLINK@Hopkins is a secure member portal where
you can keep track of your health care. View your
personal health record, review your benefit coverage,
change your primary care doctor, also called your
primary care manager (PCM), search for providers
and more. You can also self-serve many Customer
Service questions through your member portal by
visiting hopkinsusfhp.org. Under “I’m a Member” click
“Member Login.” Under “First Time Logging In?” click
“Member Register.” Fill in your member ID number,
name, birth date, gender and zip code, then click “Next”.
2. Schedule a well-visit with your PCM
Your primary care manager is an important part of your
health care. Start by contacting your PCM to schedule
a well-visit (checkup). We encourage you to schedule
this appointment within 30 days of becoming a new
member. This will allow your provider to learn about
your health and guide you for further care. Your new
PCM will also coordinate your referrals.
You have access to a fully accredited network of more
than 26,000 primary care and specialty physicians,
ensuring you can find care and services near you. If you
are currently receiving medical services outside the
Johns Hopkins US Family Health Plan network, you will
need to change to Plan-approved providers. Your new
primary care office will assist you in transferring your
records to the Plan. Remember that in order to see a
specialist or other type of provider, you must obtain a
referral from your PCM.
With our online search tool, you can find a provider by
name, search for a location convenient to you and filter
by preferences. Go to hopkinsusfhp.org. Under “I’m
a Member” click “Find a Doctor or Facility.” If you want
more information regarding a health care practitioner’s
background, qualifications and experience, call Customer
Service at 410-424-4528 or toll-free at 800-808-7347.
3. Check out our health and wellness services
Adopting and maintaining healthy lifestyle habits is as
important to your overall health as your treatment with
your providers. USFHP has helpful services to support
you in achieving your best health.
Attend one of our workshops to learn about managing
a condition or to improve your nutrition and fitness. Or,
partner with a care manager to coordinate your health
care and prevent more serious conditions.
Learn more: hopkinsusfhp.org/health-and-wellness.
Bonus: Visit the New Member page of our website
for videos to help you understand and use your plan:
hopkinsusfhp.org/new-member-information
Learn About Your Coverage
View Benefits and Costs
Our website provides detailed information about
your covered benefits, enrollment fees and applicable
cost shares. View your benefits at hopkinsusfhp.org/
my-benefits.
Explanation of Benefits (EOB)
After you receive health care services, we will mail
you an EOB that outlines exactly which services your
provider billed, what has been paid and at what rate,
what has been denied and why, and what payment, if
any, is your responsibility.
4
Johns Hopkins US Family Health Plan
1. Billed Amount: This is the amount the doctor or facility charged for the service(s) that you received.
2. Allowed Amount: This is the maximum amount USFHP will allow for the service(s) you received. Any
copay and/or co-insurance amounts that you are responsible for paying are deducted from the allowed
amount.
3. Above Maximum: The Billed Amount minus the Allowed Amount.
4. Not Covered: The amount that will not be considered for payment.
5. Deductible: The amount that you must pay within the plan year before USFHP begins to pay benefits. This
applies to the Point of Service option.
6. Copay/Co-insurance: The fixed fee you must pay at the time of service or the percentage of medical costs
that you share with USFHP.
7. Other Ins Paid: The amount another health insurance carrier pays as your primary coverage if you have
secondary insurance (or Other Health Insurance (OHI).
8. Member Liability: The amount that you are responsible for paying to the provider of service.
9. Paid Amount: Amount that USFHP has paid to the provider for the service(s) that you received.
10. Remarks: Additional information about aspects of the EOB.
Find It Online
The USFHP website (hopkinsusfhp.org) features a
great deal of helpful information and resources. Use
our website to:
• Search for health care providers by name,
location, language spoken, gender, professional
qualifications, and more
• View coverage and cost share information
• Access and download forms
• Learn about available health and wellness services
Customer Service
We also have a specially trained staff of customer
service representatives available to you between 8
a.m. and 4:30 p.m., Monday through Friday. You may
reach a representative by calling 410-424-4528 or
toll-free at 800-808-7347.
Interpreter Services
Many of our physicians and hospitals have on-site
interpreting services. To request an interpreter,
please call Customer Service at 800-808-7347.
Assistance for the hearing impaired can be accessed
through Maryland Relay by dialing 7-1-1 or 800-
201-7165.
1 2 3 4 5 6 7
8910
5
Johns Hopkins US Family Health Plan
Your coverage begins
Schedule your preventive
care
You get these services at no
extra charge when you see an
in-network provider:
• Preventive visits
• Routine physical exam
• Routine eye exam
Receive your member
ID card
You will need this for all
health care services, including
picking up prescriptions at the
pharmacy.
Sign up for HealthLINK@
Hopkins, your member portal
This is a great resource for you to
view your personal health record,
track your claims, change your
PCM, request a new ID card, and
more.
Get any additional care
you need
If you need to see a specialist, you
will need a referral from your PCM.
Use Johns Hopkins OnDemand
Virtual Care or use an urgent
care center for when you are not
able to see your PCM. Use the
emergency room for sudden and
severe injuries and illnesses.
Get your prescriptions
from Walgreens Home
Delivery
Register to have certain
medications mailed to your
home.
Pay your share
While many services are $0,
some require a cost share
(copay or co-insurance). This
is usually paid at the time of
the visit.
Catastrophic Loss Protection
Benefit
You have a catastrophic cap for
health care costs. This means
there is a limit to your out-of-
pocket expenses.
End of plan year
JAN 1
HealthLINK
Preventive Care
Copay/ Co-insurance
OnDemand
ID card
Out-of-Pocket
Walgreens
New to The Plan? Here’s How It Works With USFHP
DEC 31
6
Johns Hopkins US Family Health Plan
The back of your membership card has information for obtaining care. It also gives health care providers
information on how to process your claims. Please remember to carry this membership card with you at all
times.
Your unique membership
identification number
Effective date
Copays applicable to
your membership plan
Identifying numbers
to assist in processing
your prescriptions
Your medical practice
or PCM
SAMPLE ID CARD
(Your actual card may appear slightly different)
3
Member ID Card Overview
Your Johns Hopkins USFHP member ID card will be mailed to you from the card vendor, separately from your
welcome kit. This card provides important information about your Plan membership, relating to coverage for
primary care, specialty care, pharmacy benefits and other covered benefits. Additionally, your card provides
information about copayments and important telephone numbers, and will authorize you to receive services
under the Plan. (See below for details.)
Please carry your card with you at all times and show it at each office visit. If you also have Medicare, please
inform your provider that Johns Hopkins USFHP is your primary coverage (see page 25 for more information
on Medicare and USFHP).
If your membership ID card gets lost or damaged, you may request a new ID card and print out a temporary
card at HealthLINK at Hopkins. You may also contact Customer Service at 410-424-4528 or 800-808-7347,
Monday through Friday from 8 a.m. to 4:30 p.m.
7
Johns Hopkins US Family Health Plan
The Role of Your Primary
Care Manager
As a member of the Plan, you will establish a relationship
with a USFHP primary care manager (PCM) who will get
to know you, your medical history and your individual
health care needs. Our primary care managers are
trained in family practice, internal medicine or pediatrics.
Your PCM sees you for all of your routine health needs,
monitors the medications you receive, orders tests or
special services like physical therapy and maintains your
medical records. If you have a complex health condition,
your PCM may refer you to one of Johns Hopkins
USFHP’s many qualified specialists. Your PCM and the
Plan specialist will work together as a team to meet
your health care needs.
If You Need Specialty Care
To see a specialist or other type of provider, you must
obtain a referral from your PCM. The only exceptions
are:
• Life-threatening medical emergencies
• Routine annual vision screening exams
Your PCM will choose an appropriate specialist for your
care. If, at the time you enroll, you are under the care
of a medical specialist who practices outside the Johns
Hopkins network, your PCM may transfer your specialty
care to a Plan provider. Every effort will be made to
ensure that there is continuity in your care. Each time
you choose to see a non-Plan provider for a covered
service in a non-emergency situation, the service(s) will
be paid under the point of service (POS) provision.
Please see page 9 for a full explanation of the POS
benefit.
If You Are Admitted to a Hospital
If you require hospitalization, your PCM or specialist will
make the necessary arrangements for you. Inpatient care
will be provided at any of our participating hospitals.
Your hospital care will be coordinated by your PCM or
another Plan provider. Emergency care will be covered
at any hospital.
Note: If you are admitted to a hospital as an emergency,
your PCM must be notified as soon as possible or the
next business day.
Choosing Your Primary Care Manager
The first and most important decision you will make is
the selection of a primary care manager. Each enrollee in
your family should select a PCM with whom he or she is
comfortable. Family members do not need to select the
same PCM, and their selections may be changed upon
request.
You can locate primary care managers (PCMs) by
visiting: hopkinsusfhp.org and click on Find a Doctor.
This feature allows you to search for a doctor by city,
state, field of practice and much more. Be sure to
search for a PCM by choosing, family practitioners,
pediatricians, internists and nurse practitioners.
If you don’t have access to a computer, call Customer
Service at 410-424-4528 or toll-free at 800-808-7347
for assistance.
Hospital Services
The Plan provides a comprehensive range of hospital
benefits with no dollar or day limit when hospitalization
occurs under the care of a Plan provider. There is a
$188 co-payment per admission fee for retirees and
their family members. Active-duty families and retirees
with current Medicare Part B are not subject to the
co-payment. All medically necessary services are
covered, including:
• Semiprivate room accommodations (a private room
may be covered if a Plan provider determines it is
medically necessary)
• Specialized care units, such as intensive care or
cardiac care units
• Physician services related to medical treatment or
surgery
• General nursing services
• Operating room, anesthesia and supplies
• Prescribed inpatient drugs
8
Johns Hopkins US Family Health Plan
Accessibility of Services
Johns Hopkins USFHP members are entitled to timely
access to quality health care. The TRICARE Operations
Manual (TOM) and the Code of Federal Regulations
(CFR) establish clearly defined appointment access
standards. All in-network providers must meet these
standards when scheduling appointments for members.
USFHP member access standards are listed below.
USFHP’s Provider Relations department monitors
appointment access standards through quarterly reports.
The Plan compares the reports against regulatory and
accreditation standards, and will initiate actions as
needed when we identify improvement opportunities.
If you believe your providers are not meeting these
standards, please call Customer Service to file a
complaint.
Emergency Care
The Plan covers emergency care for sudden and
unexpected onset of life-, limb-, or sight-threatening
conditions requiring immediate attention, even when you
are traveling outside the Plan area.
If you believe that your health is in serious danger or you
are concerned that you may have experienced serious
damage to an organ or other part of your body, seek
medical care immediately by going to the nearest emergency
room or by dialing 9-1-1 for an ambulance. Some examples
of a medical emergency are:
• Major injury such as a broken leg or large wound
• Heart attack symptoms: chest pain, shortness of
breath, sweating and nausea
• Heavy bleeding
• Bleeding during pregnancy
• Major burn
• Loss of consciousness
• Difficulty breathing
• Poisoning
• Severe head pain or dizziness
Members who receive emergency care for
non life-threatening situations without a referral may
be responsible for the cost of the non-emergent care.
If you receive emergency care when away from home,
the Plan will review your claim and, if the care was
medically necessary, pay emergency benefits directly to
the providers. Any follow-up care must be coordinated
through your PCM. If you are unsure if your condition is
life-threatening, call your PCM or the USFHP NurseLine
for guidance at anytime, 24 hours a day, seven days a
week.
At the time of the ER visit, retirees without Medicare
Part B and their family members will be asked to pay a
$75 co-payment. If they are later admitted as an inpatient,
only the inpatient co-payment applies (and the $75
co-payment is waived). Active-duty family members and
retirees and their family members with Medicare Part B
do not pay co-payments for emergency room visits.
If you require follow-up care such as removal of stitches
or X-rays after your ER visit, your PCM will provide or
coordinate your care. Do not return to the emergency
room for follow-up care unless your PCM refers
you there. Reduced or no payment will be made for
unauthorized follow-up care.
After-Hours Services
24-Hour Services For USFHP Members
NurseLine
USFHP members can call the USFHP NurseLine
telephone number to speak directly to a registered
nurse any time of the day or night. Nurses will answer
questions and provide information about your medical
concerns.
USFHP NurseLine: 844-344-4218
Nurse Chat Line
For members preferring to use the Internet to obtain
general health information, Nurse Chat provides live
access to registered nurses at nurselinechat.com/
jhhcusfhp.
Johns Hopkins OnDemand
Virtual Care
Talk to a health care provider from the convenience
of your mobile device or computer. Connect from
Service
Appointment Time
(not more then)
Well Patient Four weeks
Specialist visit Four weeks
Routine Care One week
Urgent Care 24 hours
Office Visit
(wait time)
30 minutes
9
Johns Hopkins US Family Health Plan
anywhere in the U.S., no appointments needed.
Providers can diagnose and prescribe medications for
minor care concerns such as colds, rashes and pinkeye.
Service is available to members on weekdays from
6 p.m. to 8 a.m. and on the weekends. Visit
hopkinsmedicine.org/ondemand or download the app.
MedlinePlus
®
MedlinePlus is the National Institutes of Health’s Web
site for patients and their families and friends. Produced
by the National Library of Medicine, the world’s largest
medical library, it brings you information about diseases,
conditions, and wellness issues in language you can
understand. MedlinePlus offers reliable, up-to-date
health information, anytime, anywhere, for free. The
use of this site is not intended to be a substitute for
health care information provided by the plan, but may be
used as a resource to supplement the plan’s health care
information.
You can use MedlinePlus to learn about the latest
treatments, look up information on a drug or supplement,
find out the meanings of words, or view medical videos
or illustrations. You can also get links to the latest medical
research on your topic or find out about clinical trials on a
disease or condition.
Health professionals and consumers alike can depend on
it for information that is authoritative and up-to-date.
MedlinePlus has extensive information from the National
Institutes of Health and other trusted sources on over
1000 diseases and conditions. There are directories,
a medical encyclopedia and a medical dictionary,
health information in Spanish, extensive information
on prescription and nonprescription drugs, health
information from the media, and links to thousands of
clinical trials. MedlinePlus is updated daily and can be
bookmarked at the URL: https://medlineplus.gov/. There
is no advertising on this site, nor does MedlinePlus endorse
any company or product.
Non-Emergency
In The Plan Area
For non-emergency medical conditions requiring prompt
attention, call your PCM before seeking care. Most PCM
offices have evening or extended hours. They will make
every attempt to see you. If you call after office hours,
your call will be directed to the after-hours service to
provide you with information or authorize treatment
at a specific medical facility. If you are unable to contact
your PCM, you may seek care at the nearest Urgent
Care center without a referral.
Examples of conditions that might require after-hours
care include:
• Ear infection, fever, some cuts and burns, and serious
respiratory infections
• Sprains and strains
• Illnesses such as respiratory infections, chicken pox,
measles
• Backaches, earaches, sore throat
Outside the Plan Area
If you become ill or injured and require urgent, but not
emergency care while traveling, call your PCM office
during regular office hours or after-hours service. For
advice, you may contact the 24-hour nurse line at the
number on the back of your Member ID card. You can
access Urgent Care when necessary, without a PCM
referral.
Emergency or Urgent Care out of the
Country or at Sea
If you become ill or injured while in another country or
at sea and require urgent care, go to the nearest medical
facility to receive the necessary treatment. The hospital
or facility may demand immediate payment; if they
do, be sure to ask for treatment information, bills and
receipts. Within seven (7) days of your return, submit
itemized bills in English and receipts to the Customer
Service Department along with an explanation of the
services and the identification information from your
Johns Hopkins USFHP card.
Your request for reimbursement should include:
• Proof of member’s payment (copy of paid receipt,
cancelled check, credit card statement, etc.)
• Copy of itemized bill, invoice or receipt
• Description of services
• Description of diagnosis
10
Johns Hopkins US Family Health Plan
• Dates of service
• Provider ID#, name, address, phone number and
email address
• Billed amount for each service
Emergency Prescriptions
Prescriptions may be filled at any Walgreens pharmacy
in the United States. For the location nearest you, please
log onto walgreens.com.
Note: If you are unable to locate a participating
pharmacy and need to fill a prescription due to an
emergent situation, please refer to page 21 of this
handbook for details regarding coverage for emergent,
out of network pharmacy claims.
Benefits
Covered Benets
Johns Hopkins USFHP provides a comprehensive range
of preventive, diagnostic and treatment services as
defined by the Department of Defense (DoD) and the
TRICARE Prime benefit. A complete listing of covered
benefits, non-covered benefits and coverage limitations
may be found online at tricare.mil under Covered
Services, and See What’s Covered.
Although a specific benefit or service may be listed as
covered, it will be provided and paid for only if, in the
judgment of your Health Plan provider, it is medically
necessary for the prevention, diagnosis, or treatment of
an illness or condition.
Note: No oral statement of any personnel shall modify
or otherwise affect these benefits, limitations and
exclusions. Nor shall an oral statement of any personnel
convey or void any coverage, increase or reduce any
benefits under this Plan, or be used in the prosecution
or defense of a claim under this Plan.
Covered Services:
• Office visits to your primary care manager (PCM)
• Prescription drugs
• Authorized office visits to Plan specialists when your
PCM refers you
• Preventive health services: well-baby, well-child and
well-adult care
• Covered outpatient surgical procedures and
anesthesia upon referral from your PCM
• After-hours services at a Plan health center or
designated facility when authorized
• Maternity (prenatal and postpartum) and newborn
care. Note: A global authorization from your PCM is
required.
• Routine eye exams
• Emergency room visits for a medical emergency or
when authorized by the Plan
Please review the chart on page 11 of this handbook for
a list of standard medical services that are covered by
the Plan.
Point of Service (POS) Option
Self referred, non-emergency services provided by a
non-participating provider without prior authorization
will be considered for payment at the lesser of either
50% of the allowed amount or 50% of the billed charges.
POS benefits are paid only after a $300.00 individual or
$600.00 family deductible has been met. For example, if
a non-participating provider charges $500 for an office
visit and USFHP’s allowable charge is $350, USFHP
would pay $25 under the point of service option. You
would be responsible for the deductible ($300), the
50% coinsurance ($25) and the difference between our
allowable and the non-participating providers charges
($150) for a total out of pocket expense of $475. Any
amounts accrued under the point of service option do
not accrue to the catastrophic cap. To minimize out of
pocket expenses, we strongly encourage all members to
seek care within our extensive network of participating
providers.
Catastrophic Loss Protection Benet
(Catastrophic Cap)
As Johns Hopkins USFHP members, your family has an
annual catastrophic loss protection limit (or catastrophic
cap) for health care costs. This means there is a limit to
your out-of-pocket expenses.
The catastrophic cap per enrollment year for active-
duty family members is $1,256 per family, and $4,399
for retirees, retiree family members and survivors, per
family, when the sponsor entered uniformed services on
or after 1/1/2018. The catastrophic cap per enrollment
year for active duty family members is $1,000 per family,
and $3000 for retirees, retiree family members and
survivors when the sponsor entered uniformed services
before 1/1/2018. The enrollment year is based on the
12-month calendar year. Out-of-pocket expenses that
contribute toward your cap include, enrollment fees,
co-payments and cost shares. Once your catastrophic
(Continued on page 13)
11
Johns Hopkins US Family Health Plan
Plan Benefits Chart
Cost for Active-Duty
Family Members
Group A* /
Group B**
Cost for Retirees,
Family Members,
and Survivors
Group A* /
Group B**
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Reduced fees
$0
$0
$0
$0
$0
$16 generic, $43 brand
$76 non-pref brand
$13 generic, $38 brand
$76 non-pref brand
$0
$0
$0
$1,000* / $1,256**
per plan year
$0
Outpatient Services (subject to medical review)
Oce visits (Primary Care)
Specialty ofce visits
Maternity care (prenatal, postnatal)
Well-child care (birth to age 6)
Routine physical examinations
1
X-ray and lab tests
2
Ambulatory surgery (same day)
Physical therapy (when medically necessary)
Cardiac Rehabilitation
3
Inpatient Services (subject to medical review)
Hospitalization (semiprivate room and board)
Physician services
General nursing services
Diagnostic tests, including lab and X-ray
Operating room, anesthesia, and supplies
Medically necessary supplies and services
Physical therapy (when medically necessary)
Mental Health Services (subject to medical review)
Outpatient care individual
Outpatient care group
Partial hospitalization, mental health
Inpatient hospital psychiatric care
Substance Abuse Treatment (subject to medical review)
Outpatient care individual
Outpatient group/family therapy
Inpatient services (up to 7 days for detoxication per year)
Inpatient rehabilitation
Other Services
Ambulance ground services
4
(when medically necessary)
Ambulance air services
4
(when medically necessary)
Dental care (basic preventive care)
Durable medical equipment
Emergency room services
5
(including out of area)
Urgent Care Center
Routine eye examination (1 per Plan year)
Radiation / chemotherapy oce visits
Prescription drugs co-pays
6
(Participating Retail)
(up to a 30 day supply)
Prescription drugs co-pays
6
(Home Delivery Available)
(up to a 90 day supply)
Skilled nursing facility care
Home health care (part-time skilled nursing care)
Out of area (emergency services only)
Catastrophic Cap
(Maximum out-of-pocket expense per family)
Premium Fee
7
(Annual prices shown. Quarterly and Monthly are
available)
$25
$37
$0
$0
$0
$0
$75
$37
$37
$188 per admission
$0
$0
$0
$0
$0
$0
$37 per visit
$37 per visit
$37 per visit
$188 per admission
$37 per visit
$37 per visit
$188 per admission
$37 per day
$50
$20
Reduced fees
20%
$75
$37
$0
$37
$16 generic, $43 brand
$76 non-pref brand
$13 generic, $38 brand
$76 non-pref brand
$37 per day
$0
$75
$3,000* / $4,399**
per plan year
$363* / individual
$726* / family
$438.96** / individual
$879** / family
* For enlistment or appointment prior to January 1, 2018 / ** For enlistment or appointment on or after January 1, 2018
Cost for members
enrolled in
Medicare Part B
Group A* /
Group B**
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Reduced fees
$0
$0
$0
$0
$0
$16 generic, $43 brand
$76 non-pref brand
$13 generic, $38 brand
$76 non-pref brand
$0
$0
$0
$3,000* / 4,399**
per plan year
$0
(with proof of Part B
enrollment)
12
Johns Hopkins US Family Health Plan
Limitations to Benets
The Plan does not provide coverage and will not pay for:
• Services not considered medically necessary or
clinically appropriate for diagnosis and treatment as
determined by a physician
• Services or procedures that are experimental or of a
research nature, except for approved NCI trials
• Any services (including vaccinations) provided for
employment, licensing, immigration, recreational
travel, or other administrative reasons
• Cosmetic, plastic, or reconstructive surgery not
related to medical treatment
• Most custodial or convalescent care (caring for
someone’s daily needs, such as eating, dressing and
simple bandage changes) in an institution or at home
• Routine dental care and dental X-rays; treatment of
teeth, gums, alveolar process or gingival issues; cranial
mandibular disorders, and other issues related to the
joint. (Call United Concordia at 866-357-3304 for
information on discounts provided by Johns Hopkins
USFHP)
• Services provided or charges incurred prior to the
effective date of coverage under the Plan
• Services provided or received after the date your
coverage is terminated under the Plan
Note: This list is not complete and other limitations
may exist.
Examples of Specic Exclusions and
Limitations
• Abortions (routine)
• Acupuncture and acupressure
• Artificial insemination, in vitro fertilization and other
such therapies to induce pregnancy
• Autopsy and postmortem
• Aversion therapy (including electric shock and the
use of chemicals for alcoholism, except for disulfiram,
which is covered for the treatment of alcoholism)
• Chiropractic and naturopathic services
• Corrective lenses and frames
• Counseling services, unless medically necessary
• Cutting nails, trimming corns or calluses (except if
diabetic or peripheral vascular disease)
• Education or training
• Food and vitamins consumed outside a hospital
except for home parenteral nutrition therapy and
certain medically necessary foods when prescribed
and preauthorized for a covered diagnosis
• Learning disorders treatment
• Massage therapy
• Megavitamins and orthomolecular psychiatric therapy
• Orthodontia
• Orthopedic shoes and orthotics, except when part of
a brace or in connection with medical treatment, e.g.,
diabetes treatment
• Private hospital rooms, unless ordered by the
attending physician for medical reasons or if a
semiprivate room is not available
• Radial keratotomy
• Retirement homes
• Some sexual dysfunction treatments
• Sterilization reversals
• Work-related illnesses or injuries that are covered
under workers’ compensation programs
Other exclusions may apply as defined by the TRICARE Prime benefit.
Check with a customer service representative for further clarification.
Footnotes to Plan Benets Chart
1. 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.
2. 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.
3. Outpatient treatment following the initial intake evaluation and testing is limited to a maximum of 36 sessions per cardiac event.
4. Upon arrival of the ambulance and member refuses transport, the member is liable/responsible for services rendered.
5. Unless you are admitted to the hospital, in which case only the inpatient co-payment applies.
6. 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.
13
Johns Hopkins US Family Health Plan
cap has been met, you and your family members will not
have to pay any more out-of-pocket expenses for the
remainder of that calendar year.
Johns Hopkins USFHP encourages you to keep track of
your out-of-pocket expenses. If you find a discrepancy
in the amount the Plan has credited toward your
cap, please send receipts with sponsor’s name and
membership identification number to:
Johns Hopkins USFHP
Premium Billing Department
7231 Parkway Drive, Suite 100
Hanover, MD 21076
410-424-4835
toll-free: 888-717-8282
fax: 410-424-4770
Note: Dental charges under United Concordia’s
“Concordia Advantage Network” do not count toward
the catastrophic cap.
Other Services
Ambulance Service
Benefits are provided for medically necessary, life-
sustaining, ambulance-transport services furnished
when use of any other method of transportation is
inadvisable. If you are a retiree over age 65 or a retiree
family member and you do not carry Medicare Part B,
your co-payment is $50 per occurrence for ambulance
services. Active-duty family members and retirees with
current Medicare Part B do not have a co-payment for
ambulance services.
Dental Care
Johns Hopkins USFHP, under a separate agreement has
arranged for members to receive dental services from
participating community dentists referred to as the
Concordia Advantage Network.
Call Concordia Advantage Network at 800-332-0366 or
visit Johns Hopkins USFHP Client’s Corner page at ucci.
com/jhusfhp for more information about specific dental
benefits.
What’s Covered
Two routine dental cleanings per year are covered.
(Billing codes associated with the routine cleanings are
D1110 for adults, defined as those members who are
age 13 and up, and D1120 for children up to age 13.)
How to Obtain Your Free Cleaning
Call or go to the UCCI Client’s Corner page for the list
of Concordia Advantage Network providers in your area.
• Select a provider. Call for an appointment.
• Confirm that the provider participates in the
Concordia Advantage Network.
• At the time of the appointment, show your
Johns Hopkins USFHP membership card when you
check in.
• Your dentist will bill United Concordia directly for
the cost of the cleaning. You will have no out-of-
pocket expense for the cleaning.
Coverage Limitations
Other services that may be associated with the cleaning,
such as X-rays, fillings, etc., are not covered by Johns
Hopkins USFHP. However, discounts for these other
services may exist as applicable by law. If you receive
other services listed on the Concordia Advantage
Network Member Fee Schedule, you will be expected
to pay the dentist directly at the reduced rate. If you
receive a service that is not listed on the fee schedule or
you receive dental care outside of the service area, you
will be responsible for the dentist’s normal charges for
that visit.
Vision Care
Covered Benefit
One routine eye examination per year, including
refractions and written lens prescription, may be
obtained from designated Plan providers. You may
obtain eye care at any Johns Hopkins Wilmer Eye
Institute, Superior Vision provider location, or
contracted community provider. Call Superior Vision at
14
Johns Hopkins US Family Health Plan
800-428-8789 or visit https://superiorvision.com to
find the nearest locations.
• Diagnosis and treatment of eye disease is covered in
the same manner as any other medical specialty and
requires a referral from your primary care manager
(PCM).
Non-Covered Benefit
• Corrective vision lenses, frames, corrective vision
contact lenses and contact lens fittings are not
covered.
• Corrective vision surgery is not covered (e.g.,
LASIK*, radial keratotomy, PRK, etc)
*A discount on laser vision correction services is
available to members. For more information, visit
hopkinsusfhp.org/dental-vision-and-discounted-services.
Note: Under a separate agreement, Johns Hopkins
USFHP has arranged for Plan members to receive
discounted prices for corrective lenses and frames at
all Wilmer Optical Shops and Superior Vision locations.
For more information please visit: hopkinsusfhp.
org/members/my-benefits/dental-vision-and-
discounted-services/
Diagnostic Services
If requested by your primary care manager or specialist,
the following may be covered without an additional
co-payment when performed by a participating provider:
• Pathology/lab services
• Nuclear medicine services
• Cardiovascular studies
• Radiology/ultrasound services
However, if you have a PCM or specialist office visit on
the same day as the diagnostic services, a co-pay will be
collected from retirees and their family members who
do not carry Medicare Part B for the PCM/specialist
visit. Active-duty family members and retirees with
current Medicare Part B are not required to pay co-pays
for most services.
Hospice Care
Hospice care provides an integrated set of services
and supplies for the care of the terminally ill. This
type of care emphasizes palliative care and symptom
management through supportive services, such as some
limited multidisciplinary home care, inpatient symptom
management and periodic, brief, inpatient respite-care
stays. The benefit provides coverage for a humane and
sensible approach to care during the end of life for
terminally ill patients.
Note: Eligibility determinations and referrals to
approved hospice care providers are made by primary
care managers or specialists using established medical
criteria.
Behavioral Health
What Is Covered
The Plan provides medically and psychologically
necessary services for the diagnosis and treatment of
substance abuse and mental health conditions provided
by licensed professionals including psychiatrists,
psychologists, clinical social workers, and, certified
marriage and family therapists.
Covered services include:
• Diagnostic evaluation
• Behavioral therapy (positive reinforcement methods
only)
• Psychological testing subject to medical review
• Psychiatric treatment (including individual and group
therapy)
• Hospitalization (including inpatient professional
services), subject to behavioral health review
For office based mental health services Johns Hopkins
USFHP members may self-refer to an in-network
participating mental health provider. For behavioral
health care provider locator and appointment assistance,
please call 888-309-4573.
Treatment for chemical and alcohol dependency at
approved in-network inpatient treatment facilities is
covered when preauthorized by the Plan.
If a new Plan member is currently under treatment
for a mental health condition or chemical or alcohol
dependency from a non-Plan provider, please call 410-
424-4830 or 888-281-3186 to transfer your care to a
Plan provider. The Plan covers only approved services
from an in-network participating provider.
What Is Not Covered
Every effort is made to assist members to obtain the
necessary services at the right level of care. There are
some exclusions to the Plan. The following are examples
of excluded services:*
• Treatment of disorders of sexual functioning
• Support services and groups that are not time-
limited or not conducted by a licensed professional
• Learning disabilities including psychological testing
for academic and intelligence testing
* Other limitations may exist.
15
Johns Hopkins US Family Health Plan
National Cancer Institute Clinical Trials
Through its contract with the DoD the Plan has access
to the National Cancer Institute (NCI) to treat patients
who suffer from cancer. Plan members who meet
specific criteria will have access to promising new cancer
therapies in test stages. If accepted to a clinical trial,
patients will have access to treatment. The DoD finances
some of the sponsored studies including Phase II and
Phase III protocols approved by the NCI for all types of
cancer. Phase I cancer trials will be covered for USFHP
on a case by case basis. Medical review and approval
will be done to validate criteria for coverage has been
met. More information is available about this program
at cancer.gov. If you are interested in participating in the
program, please contact the Plan’s Care Management
Department at 800-556-0196.
Durable Medical Equipment
Durable medical equipment may be covered if deemed
medically necessary and prescribed by your primary care
manager and purchased or rented from a Plan provider.
A 20% co-insurance is applied for retirees and their
family members who do not carry Medicare Part B.
Active-duty family members and retirees with current
Medicare Part B are not responsible for the co-payment.
ECHO (Extended Care Health Option)
ECHO provides financial assistance only for active-
duty family members with specific qualifying mental or
physical conditions. Some conditions include (please
note this is not an all-inclusive list):
• 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
ECHO Benets
ECHO benefits, services and supplies are not available
through the basic Johns Hopkins USFHP. ECHO benefits
provide such coverage as:
• 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
• Transportation under certain limited circumstances
(includes the cost of a medical attendant when
needed to safely transport the beneficiary)
All ECHO services require preauthorization
through Johns Hopkins USFHP Utilization
Management.
ECHO Eligibility Process
For general questions, potential ECHO enrollees or
family members may call the USFHP customer service
telephone number at 410-424-4528 or 800-808-7347.
USFHP also has a dedicated ECHO team. A member of
the ECHO team will assist members by answering more
detailed questions regarding the eligibility and enrollment
process.
To enroll in the ECHO program, members must be
currently enrolled in Johns Hopkins USFHP, 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.
ECHO Costs
Active-duty sponsors pay a cost-share that is based
on their pay grade and is separate from other USFHP
16
Johns Hopkins US Family Health Plan
program cost-shares. The monthly cost-share is one fee
per sponsor, not per ECHO beneficiary.
Sponsor’s Pay Grade
E-1 to E-5
E-6
E-7, O-1
E-8, O-2
E-9, WO/WO-1,
CWO-2, O-3
CWO-3, CWO-4, O-4
CWO-5, O-5
O-6
O-7
O-8
O-9
O-10
Monthly Cost-Share
$25
$30
$35
$40
$45
$50
$65
$75
$100
$150
$200
$250
The maximum government cost-share is $36,000
per beneficiary, per calendar year (CY) (January 1st -
December 31st). Sponsors are responsible for the cost
of ECHO benefits that exceed this limit.
Note: The ECHO Home Health Care (EHHC) benefit
is not subject to the $36,000 per CY maximum
government cost-share. The sponsor’s cost-share does
not count toward the annual catastrophic cap. ECHO
costs cannot be shared between family members.
For more information about ECHO, you can also
visit tricare.mil (see benefit information) or go to
hopkinsusfhp.org/plan/benefits-costs/discounts/.
Evaluation of New
Technology, Drugs and
Benefits
A TRICARE benefit must meet three basic
requirements:
• It cannot be excluded by law (statute) or regulation
(Code of Federal Regulations)
• It must be medically necessary and appropriate
(proven, safe and effective) and represent the
standard for good health care in the United States
• It must be funded and administratively added to the
TRICARE program
New benefits or revisions of existing benefits are
made by the Department of Defense Defense Health
Agency (DHA) after extended research, review, and
collaboration. The need for benefit changes are identified
by:
• Reviewing changes to federal law
• Monitoring changes in national health care coverage
and reimbursement
• Requests for scientific review from within and
outside DHA
• Researching and reviewing appeals of denied services
under the current benefit program
Care Management
At no cost to you, the USFHP Care Management
program offers you the tools and ongoing support you
need to better understand and manage your health.
USFHP's Care Management services give you individual
support and services that are designed to help you
understand and self-manage your medical conditions.
It can be overwhelming to manage all of your
health needs. If you need help with this, ask for a care
manager. Care managers are registered nurses and
licensed clinical social workers who can teach you more
about your conditions and how to manage them. They
work with all of the providers in your care team. They
advocate for you to help you achieve your best health.
No matter where you are on your health journey, we
have services to support you. Your USFHP care team is
ready to help you do more for your health.
You, your care manager, and your health care providers
can collaborate to improve your health by:
• Determining your personal needs and wellness
• Building your skills to help you better manage your
conditions
17
Johns Hopkins US Family Health Plan
• Helping with referrals to specialists
• Managing the supplies and services you need for
your health care
Work with a care manager if you:
• Are pregnant
• Have a chronic health condition like diabetes,
hypertension, or COPD
• Are ending a hospital stay
• Want help with advance care planning
Preventive Health
Johns Hopkins USFHP wants to help you to avoid
complications and stay healthy. The Plan will remind you
of services you need and give you information that you
can trust.
Care Managers can provide you guidance on timely
health screenings, annual well checks, immunizations,
as well as refer you to our health education classes and
health library to help you manage your health and stay
as healthy as possible.
Transitional Care
Care Managers can provide you with assistance
navigating the health care system following a health event
such as an emergency room (ER) visit, hospitalization,
new diagnosis or significant life event. Care Managers can
help you get the appropriate provider follow-up after an
ER visit, hospitalization or significant life event, as well as
access to the medications or other medical supplies you
need to continue your treatment. Care Manager support
as you transition from one treatment setting can help
you better manage your health and reduce the need to
go to the hospital.
Complex Care
Johns Hopkins USFHP can guide you to partner with a
registered nurse or licensed clinical social worker, who
can work with you one-on one to help you learn about
a new diagnosis, help you coordinate your care, help you
improve your knowledge and skills in managing a chronic
health condition, and collaborate with your providers to
make sure you understand and know how to take the
best possible care of your conditions.
Behavioral Health
Your mental wellness is vital. If you struggle with anxiety,
depression, or other behavioral health (mental health)
conditions, including challenges with substance abuse,
you can receive confidential support from USFHP
behavioral health care managers, who are licensed
clinical social workers. A behavioral health care manager
can help you navigate your treatment needs as you take
steps toward wellness. Working with a behavioral health
care manager, you will receive telephonic support, care
coordination between all of your providers, and other
resources that may help supplement your treatment.
Maternal/ Child Health
Johns Hopkins maternal/ child care managers can also
help you if you are pregnant, postpartum or a parent/
caregiver of newborns and children. Registered nurse
care managers can provide you with care coordination,
health education and help connect you to services and
resources for you and your family. If your baby needs
care in the NICU, maternal/ child health care managers
work with you to help you understand your baby's care
needs, assist you in the transition home.
If you’re ready to talk, your care team is ready to help.
How to Self-Refer
Johns Hopkins USFHP encourages you to take advantage
of the services and programs provided by Care
Management. Care Management services are voluntary
and are provided at no cost to members. Members
identified with certain needs may be automatically
enrolled, but there is no obligation to participate in
these programs.
You can opt out of the services at any time by
contacting Care Management.
If you have questions about our Care Management services,
or if you would like to refer yourself or a loved one to a
program, call toll-free at 800-557-6916. This number may
also be used to opt-out of Care Management services. We
are available Monday through Friday, 8:30 a.m. to 5:00 p.m.
Any voicemail messages received after normal business
hours will be addressed the next business day. We can also
be contacted by e-mail at [email protected].
For more information about how to use Care Management
services, go to hopkinsusfhp.org/health-and-wellness/
care-management/.
Health Education
You may also receive assistance from our Health
Educators who advocate, encourage and teach you
about healthy lifestyles and living well with a chronic
condition. Our Health Educators offer health education
classes and activities, and collaborate with our care
18
Johns Hopkins US Family Health Plan
managers to provide important health education to
support your treatment needs. You may attend one of
our many interactive programs to give you information,
tips and tools to better manage your health.
There is always something new to learn about staying
healthy. Johns Hopkins USFHP offers a wide variety of
interactive health education programs and workshops
to teach you how to take better care of yourself.
Best of all, these programs offer a supportive group
environment where members can encourage each other
and learn from one another’s experiences.
Topics include:
• Diabetes
• Pre-diabetes
• COPD (Chronic Obstructive Pulmonary Disease)
• Asthma
• Blood Pressure
• Heart Disease
• Nutrition
• Weight Management
• Physical Activity
• Quitting Smoking
• Sleep
• Stress Management
For more information regarding virtual health education
classes, go to hopkinsusfhp.org/health-and-wellness/
health-education/ or call 800-957-9760 or email
Utilization Management
(UM)
The USFHP’s Utilization Management evaluates requests
for services that require prior authorization. Services
that may require a prior authorization from Utilization
Management before services are provided may include:
specialty medical care, inpatient mental health treatment
and inpatient substance-abuse treatment. The Johns
Hopkins USFHP Member Handbook “If You Need
Specialty Care” section describes how to obtain a
referral for specialty care.
The goals of the UM program are to:
• Provide a system of pre, post and urgent requests
for authorizations are evaluated to determine the
necessity and/or appropriateness of services being
authorized;
• Ensure continuity and consistency of benefit and
clinical criteria administration;
Utilization management decision making is based only
on appropriateness of care and service, and existence
of coverage. No person may participate in the review
of any case, which he/she has professional or personal
involvement or where judgment may be compromised.
There are no rewards to practitioners, providers or
Utilization Management staff to encourage barriers
to care and service through the issuance of denials of
coverage or requested services. There are no financial
19
Johns Hopkins US Family Health Plan
incentives for UM decision makers to encourage
decisions that result in underutilization of services.
Often this requires Prior authorization by the health
plan and is required for certain services and/or elective
hospital admissions. Utilization management decision
making is based on appropriateness of care and
service, and existence of coverage. Licensed medical
professional administer the UM policies and procedures
and may approve services, and the Plan Medical
Director reviews and renders all UM denials involving
medical necessity, cosmetic and/or investigational
decision making. For additional information on services
requiring authorization refer to the USFHP website
hopkinsusfhp.org/members/plan-documents/.
UM staff is available at least eight hours a day during
normal business hours for inbound collect or toll-free
calls regarding UM issues. After normal business hours, a
phone message can be left which staff will return on the
next business day. To contact Utilization Management,
call 410-424-4480 or 800-261-242. TDD/TTY services
are available for members who need them by contacting
the Maryland Relay operator at 711 or 800-201-7165,
8am - 5pm. Language interpreter assistance is available
as needed and can be requested by contacting USFHP
Customer Service at 410-424-4528 or 800-808-7347.
Pharmacy and Prescription
Drug Services
Retail Pharmacy Network
You may obtain your prescriptions at any of the
approximately 8,100 Walgreens network pharmacies
nationwide. You may fill prescriptions for up to a 90-day
supply of medications. To fill a prescription, present
your Johns Hopkins USFHP Member ID Card to the
pharmacist with your prescription. You will be required
to pay a co-payment (co-pay) at the time of service.
Your ID card contains important information to allow
the pharmacy to process your claim correctly. For
the location of a Walgreens pharmacy near you, visit
walgreens.com.
Note: You may not obtain prescriptions from a Military
Treatment Facility and government/federal military
pharmacies, including Veterans Affairs (VA) pharmacies
while enrolled in USFHP. Prescriptions that originated at
a military treatment facility may not be transferable to
Walgreens pharmacies.
Any prescriptions filled outside of Walgreens’ 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.
This includes prescriptions filled from a non Walgreens
Pharmacy during inpatient stays at nursing or assisted
living facilities. See the section titled “Out of Network
Claims.”
Home Delivery/Mail Order Pharmacy
Home delivery is available to USFHP members for up
to a 90-day supply of approved medications through
Walgreens. Home delivery is best suited for medications
you take on a regular basis.
If you live in Maryland, you may obtain your prescription
through home delivery by completing the Pharmacy
Home Delivery (Maryland residents) form, available
at hopkinsusfhp.org/members/plan-documents. Once
completed, send it in with your new prescription, plus a
check or credit card number for your copayment, to the
address listed on the form. To ensure you receive a refill
before your current supply runs out, reorder at least
two weeks before you need your refill.
If you live outside of Maryland, you may obtain your
prescription through home delivery from AllianceRx
Walgreens Prime pharmacy. For more information,
visit the AllianceRX Walgreens Prime website at
alliancerxwp.com/home-delivery.
To obtain home delivery, fill out the Out of State
Pharmacy Home Delivery form, available at
hopkinsusfhp.org/members/plan-documents, and
mail to the address listed on the form.
To request refills, you may submit the form electronically
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Johns Hopkins US Family Health Plan
by logging into your HealthLink@Hopkins account.
Attach the completed form to a new message in
your Message Center and then send the message to
Customer Service. Your request will be forwarded to
the Walgreens Pharmacy for fulfillment.
Your prescription order is processed promptly and
most orders are received within two weeks. To ensure
you receive a refill before your current supply runs out,
re-order at least two weeks before you need your refill.
Failure to include appropriate co-payment amount may
delay delivery of your medication.
Vaccine Administration at Walgreens
Pharmacies
The Centers for Disease Control (CDC) recommends that
everyone 6 months of age and older receive the flu vaccine.
Vaccination is especially important for health care workers,
young children, pregnant women, people with chronic health
conditions and people age 65 years and older.
Influenza is a contagious disease spread by coughing,
sneezing, and nasal secretions. Vaccination is the best
protection against getting the flu! Get your free flu
vaccine at your Walgreens pharmacy and protect
yourself from flu symptoms all season long.
USFHP members (9 years of age and older) can receive a
free flu vaccine at participating Walgreens vaccine network
pharmacies. This convenient option lets you get a vaccine
even if you can’t make it to your physician’s office. And best
of all, there is no cost to you.
Travel Vaccines:
Certain vaccines are covered when required by
dependents of active duty military personnel who are
traveling outside of the U.S. as a result of an active
duty member’s duty assignment. Travel orders and a
physician’s prescription must accompany immunization
voucher requests. Age restrictions apply. Email requests
Other Vaccines:
You can get some covered vaccines at $0 from
participating Walgreens pharmacy.
COVID-19: Adult and pediatric COVID-19 vaccines
that are authorized or approved by the Food and Drug
Administration are covered at $0 for members. Johns
Hopkins USFHP and Johns Hopkins Medicine encourage
all individuals to receive the vaccine and all families to
consider having eligible children get the appropriate
COVID-19 vaccine. Members can receive the vaccine
from any Walgreens pharmacy.
You may find a participating Walgreens vaccine network
pharmacy at walgreens.com.
Formulary and Co-Payments
Johns Hopkins USFHP utilizes the TRICARE pharmacy
formulary. The TRICARE pharmacy formulary is a list
of generic and brand prescription drugs that are covered
under the TRICARE benefit. The TRICARE Formulary
Search Tool can be found at express-scripts.com/
frontend/open-enrollment/tricare/fst/#/. USFHP
members are responsible for a portion of the cost of their
medications. The TRICARE formulary contains three cost
levels for USFHP members. The cost shares are as follows:
Walgreens Retail (up to a 30 day supply)
Generic: $16 / Brand Name: $43 / Non-Formulary: $76
Walgreens Retail and Home Delivery
(up to a 90 day supply for maintenance medications)
Generic: $13 / Brand Name: $38 / Non-Formulary: $76
You can view the cost share for a medication using
the TRICARE Formulary Search tool found on our
Web site under Members & Visitors, Pharmacies &
Medications, Formulary. You can also use the search
tool to find lower cost alternative medications to a
medication you are currently taking.
Covered Medications
The Johns Hopkins USFHP Pharmacy Program covers
medications that are approved by the U.S. Food and
Drug Administration (FDA) and that generally require a
prescription. Other covered medications include:
• Insulin
• Insulin syringes and needles
• Smoking Cessation products at no out of pocket cost
(Max of 2 quit attempts per yr.)
• Glucose test strips*
• Lancets
• Prenatal Multivitamins with a prescription
* Freestyle Lite & Precision Xtra strips are TRICARE
preferred test strips. All other test strips will require
prior authorization.
* Continuous glucose monitors (CGMs): FreeStyle
Libre® Kit 2 sensor & reader, FreeStyle Libre® kit
3 sensor & reader, Dexcom G6® sensor, receiver
& transmitter, and Dexcom G7® sensor & receiver
(These CGMs require prior authorization at your local
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Johns Hopkins US Family Health Plan
pharmacy and through home delivery)
All regular glucose monitors and continuous glucose
monitors, such as Free Style Libre and Dexcom, are
covered by your USFHP medical benefit. Use the
Durable Medical Equipment (DME) directory, available
at hopkinsusfhp.org/members/plan-documents, to
find a supplier.
Non-Covered Medications
Prescription medications used to treat conditions that
are not currently covered by USFHP, either by statute
or regulation, are likewise excluded from the pharmacy
benefit. Excluded medications include but are not limited
to:
• Drugs prescribed for cosmetic purposes
• Fluoride preparations
• Food supplements, formulas and medical foods
• Homeopathic and herbal preparations
• Smoking cessation products covered under the
smoking cessation benefit
• Any drugs otherwise excluded by the
TRICARE Pharmacy Formulary
Formulary
Johns Hopkins USFHP utilizes the TRICARE Pharmacy
Formulary. The TRICARE formulary and pharmaceutical
management policies are developed by the Department
of Defense Pharmacy and Therapeutics Committee.
The TRICARE formulary is a tiered, open formulary and
includes generic drugs (Tier 1), preferred brand drugs (Tier
2), and non-preferred brand drugs (Tier 3). Additional
information about the DoD Pharmacy and Therapeutics
review and list of formulary drugs can be found at health.
mil/formulary.
Generic Drug Policy
Generic drugs are chemically identical to their branded
counterparts. They are made with the same active
ingredients, and produce the same effects as their brand
name equivalents. The Food and Drug Administration
(FDA) requires generic drugs to have the same quality,
strength, purity, and stability as brand name drugs. Also,
the FDA requires that all drugs including generic drugs
be safe and effective. Generic drugs usually cost less
than brand name drugs; you can save money on your
co-payment by choosing generic drugs when applicable.
Additional information on generic drugs is available on
the FDA web site at: fda.gov/Drugs/default.htm.
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
dispensed only if your physician submits a medical
necessity request and approval is granted by USFHP.
In those cases you will pay the brand-name co-payment.
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. Use the Pharmacy Prior
Authorization form for establishing medical necessity
for applicable drugs, found at hopkinsusfhp.org/
members/plan-documents/. To determine a drug’s
eligibility for medical necessity visit the TRICARE
Formulary website at: express-scripts.com/frontend/
open-enrollment/tricare/fst/#/.
Quantity Limits
The Department of Defense Pharmacy and Therapeutics
Committee has established quantity limits for certain
medications. If your medical condition warrants use
of quantities greater than the listed quantity limit for
your medication, your provider may submit a Prior
Authorization request for use of the higher quantity.
Your physician must provide medical justification for
use of the higher quantity. To determine if there is
a quantity limit on a medication you take, use the
TRICARE Formulary Search tool and view drug specific
information: express-scripts.com/frontend/open-
enrollment/tricare/fst/#/.
To initiate a quantity limit prior-authorization your
provider must complete and fax the Prior Authorization
form to the Johns Hopkins Health Plans Pharmacy
Review department at 410-424-4607.
To download a copy of the Pharmacy Prior-
Authorization form, visit here: hopkinsusfhp.org/
members/plan-documents/.
Prior Authorization
Some medications require Prior Authorization (PA)
before they can be dispensed.
To determine if a medication requires a PA, use the
TRICARE Pharmacy Formulary Search Tool at: express-
scripts.com/frontend/open-enrollment/tricare/
fst/#/
To initiate a prior-authorization your provider must
complete and fax the Prior Authorization form to
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Johns Hopkins US Family Health Plan
the Johns Hopkins Health Plans Pharmacy Review
department at 410-424-4607.
To download a copy of the Pharmacy Prior-
Authorization form, visit here: hopkinsusfhp.org/
members/plan-documents/.
Step Therapy
Step therapy involves prescribing a safe, clinically
effective, and cost-effective medication as the first step
in treating a medical condition. The preferred medication
is often a generic medication that offers the best overall
value in terms of safety, effectiveness and cost. Non-
formulary 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 on the TRICARE Formulary.
Note: If you filled a prescription for a step therapy
drug within 180 days prior to the implementation of
step therapy, you will not be affected by step therapy
requirements and will not be required to switch
medications.
Medical Necessity for Non-Formulary
Medications (at Formulary Co-payments)
Medical necessity criteria are established by the DoD
Pharmacy & Therapeutics (P&T) Committee for each
non-formulary medication. If the medical necessity
criteria are met, the beneficiary may receive the non-
formulary medication at a lower co-payment where
applicable. Your provider can establish medical necessity
by completing and submitting the Pharmacy Prior
Authorization form.
To download a copy of the Pharmacy Prior-
Authorization form, visit here: hopkinsusfhp.org/
members/plan-documents/.
Out of Network Claims/
Reimbursement
In the event that you fill a prescription at an out of
network pharmacy due to an emergent situation,
you may seek reimbursement for the incurred cost.
To obtain reimbursement, complete the Prescription
Reimbursement Claim form and mail to the address
indicated on the form. You will be reimbursed for the
cost of the prescription less applicable co-payment. Any
prescriptions filled outside the Walgreens 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.
This includes prescriptions filled from a non-Walgreens
Pharmacy during inpatient stays at nursing or assisted
living facilities.
To download a copy of the Prescription Reimbursement
Claim Form, visit here:
hopkinsusfhp.org/members/plan-documents/.
Online Coordination of Benets
USFHP beneficiaries who have other health insurance
(OHI) can take advantage of online coordination of
benefits (COB). Tell your pharmacist you have Johns
Hopkins USFHP coverage in addition to your OHI when
you have your prescription filled at your retail network
pharmacy. Your pharmacist will submit your prescription
online to both plans at the same time. The online COB
process is only applicable at Walgreens pharmacies. If
your primary insurance requires use of a pharmacy other
than Walgreens, you may seek reimbursement for the
eligible portion of your out of pocket expense. To obtain
reimbursement, complete the Prescription Drug Claim
form at hopkinsusfhp.org/members/plan-documents/
and mail to the address indicated on the form.
Advantages of having your COB claims processed online
include:
• Zero out-of-pocket expense
• No need to submit paper claims
• Reduced or eliminated up-front costs
Johns Hopkins USFHP becomes the first payer when:
• The drug is not covered by your OHI, but is covered
by TRICARE
• Coverage under your OHI is exhausted for the
benefit year
Specialty Medications
Specialty medications are used to treat complex, long-
term conditions. These are medications that may need
special storage or have side effects that your health care
provider needs to monitor. Some of these medications
are covered by your pharmacy benefits and some are
covered by your medical benefits.
Specialty medications covered by your pharmacy
benefit are available at a local pharmacy. You take
these medications on your own. For some of them,
your provider may have to ask Johns Hopkins USFHP
to approve them. Search the TRICARE Formulary for
the specialty medications covered under the pharmacy
benefit.
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Johns Hopkins US Family Health Plan
Some medications may not be available at local network
pharmacies because of the medication’s manufacturer
limits. If your physician submits a request for use of a
limited or restricted distribution drug, upon approval
Johns Hopkins USFHP will forward the request to a
contracted specialty pharmacy. The specialty pharmacy
will coordinate delivery of the medication to the patient’s
home or physician office.
Specialty medications covered under your medical benefit
are either given to you by your provider or taken while
your provider is there with you. Some of these medical
drugs may require prior authorization and your provider
may have to ask Johns Hopkins USFHP to approve them.
Your doctor may find a list of medical drugs that
have this prior authorization requirement and more
information about how to submit a prior authorization
request by visiting hopkinsusfhp.org/members/
my-benefits/pharmacy.
Drug Information
To view information on a drug, generic availability, how
to take the medication, possible side effects, risks and
drug interactions visit: walgreens.com
Prescription Drug Recalls
Johns Hopkins USFHP cares about your safety.
When Walgreens is notified by the Food and Drug
Administration (FDA) about a Class I, Class II or
voluntary drug recall, on behalf of USFHP, they promptly
notify affected members and their prescribing doctors by
mail.
For Class I recalls, situations where there is reasonable
probability of a serious adverse health consequences
caused by a medication, members and prescribers will be
notified within 7 calendar days of health plan notification
by the FDA.
For Class II recalls, where a medication may cause
temporary or medically reversible adverse health
consequences, or in the case of a drug withdrawal from
the market by a manufacturer, members and prescribers
are notified within 30 calendar days of health plan
notification by the FDA.
Members who receive recall notices are urged to contact
their prescriber for further instructions. More information
regarding drug recalls, market withdrawals and safety
information can be found at fda.gov.
Skilled Nursing Care
Inpatient Skilled Nursing Care
The Plan provides inpatient skilled nursing care in an
accredited, contracted skilled nursing facility when it is
medically necessary. Coverage includes:
• Bed, board and skilled nursing services in a subacute
or rehabilitation facility
• Drugs, biologicals, supplies, and equipment ordinarily
provided or arranged by the facility when authorized
by a Plan provider
• Other medically necessary treatments and services
deemed appropriate
Note: Short- or long-term custodial care is not covered.
Home Care
The Plan provides medically necessary home care for
beneficiaries who are homebound or whose condition is
such that home visits are indicated, including:
• Durable medical equipment such as wheelchairs,
hospital beds, oxygen, and respirators when
arranged by the Plan
• Home physical therapy, speech therapy, or
occupational therapy for short, defined periods
when significant improvement can be expected
Note: Home care is covered only when such care is
medically necessary and authorized by the Plan and is
limited to skilled services. Assistance with the ordinary
activities of daily living such as eating, dressing, etc., is not
covered.
Enrollment In The Plan
Enrollment in Johns Hopkins USFHP is for an
automatically renewing one-year period, unless your
eligibility or standing changes. Beneficiaries may choose
to enroll, change, or terminate coverage during Open
Season, which begins the Monday of the second full
week in November and ends the Monday of the second
full week in December of each calendar year. Once
enrolled, members may not disenroll until after the
12-month period, unless they experience a Qualifying
Life Event (QLE), or they fail to pay applicable premium
fees. Upon disenrollment, a beneficiary can continue to
see his or her primary care manager under TRICARE
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Johns Hopkins US Family Health Plan
Select or Medicare/TRICARE For Life as long as
the beneficiary is still eligible through the Defense
Enrollment Eligibility Reporting System (DEERS).
Enrollment changes can be made within 90 days of a
QLE. If no enrollment changes are made, coverage will
continue from year-to-year unless otherwise terminated.
Eligibility
To maintain your enrollment in the Plan, you must be
registered with DEERS as eligible to receive health care
benefits and have a valid Military ID. To maintain your
coverage, keep your DEERS record up to date. If you
have any questions about your DEERS eligibility, call 800-
538-9552 or go to https://www.tricare.mil/DEERS
Beneciary Web Enrollment (BWE)
You can make changes to your DEERS account as well
as enroll in Johns Hopkins USFHP using TRICARE’S
Beneficiary Web Enrollment (BWE) portal. You can access
the portal by logging onto hopkinsusfhp.org and going to
the Enroll Now section.
To log on you must have one of the following:
• Valid CAC (Certified Common Access Card)
• DFAS (Defense Financial and Accounting Services)
myPay login ID and password
• Department of Defense Self-Service Logon
Some of the features include:
• Enroll or Transfer enrollment to a new region
• Update personal contact information such as
address, phone number and email in DEERS and
USFHP
• Make initial credit card payment
• Convert enrollment from active duty to retiree
status up to 60 days before retirement (DEERS must
reflect retirement status)
• Add information about other health insurance to
your DEERS record
• View enrollment information
Military Treatment Facility Privileges
As a condition of membership, Plan members are not
permitted to use a military treatment facility (MTF) for
non-emergency care, including the MTF pharmacy. MTF
pharmacies are not included in the USFHP network
and cannot be used. However, should you experience a
life- or limb-threatening emergency, you are permitted
to use the nearest civilian or military emergency facility.
You must notify your primary care manager within 24
hours of receiving care. Claims for emergency treatment
should be submitted to the Plan for payment.
Changes Aecting Eligibility
Adding a Family Member (except a newborn
or adopted child)
Your family member is not automatically covered by
TRICARE Prime. To make sure your family member is
enrolled in TRICARE Prime, you must complete two
steps.
• Update your family member’s eligibility in DEERS by
visiting a RAPIDS site and
• Submit a TRICARE Prime Enrollment Application
and Primary Care Manager Change form (DD Form
2876), or you may enroll online via the Beneficiary
Web Enrollment Web site at dmdc.osd.mil/appj/
bwe/ or telephone your request.
Having a Baby or Adopting a Child
TRICARE -eligible newborns are considered TRICARE
Prime as of the date of birth if the uniform services
member sponsor is showing as eligible in DEERS
(enrolled or non enrolled), or the non-active duty
sponsor or another family is enrolled in Prime.
Please notify the Enrollment Department as soon as
possible after the birth or adoption of the child in order
to expedite payment of all delivery charges. In addition,
the newborn or adoptee needs to be enrolled in DEERS
within 90 days from the date of birth or adoption.
Failure to register your child into DEERS within 90 days
will result in termination of your child’s membership in
Johns Hopkins USFHP on the 91st day after his/her birth
or adoption. The effective date of coverage for a newborn
whose mother is not a member of the USFHP is the date
we receive the application for enrollment of the infant.
Also, the newborn must be enrolled in Johns Hopkins
USFHP at the time the application is received.
Change of Address
Please let us know if your mailing address within our
service area changes for any reason by contacting the
USFHP.
Active Duty to Retired
A TRICARE Prime enrollment request (enrollment
form, BWE Transaction, or telephonic) must be received
within 30 days of the sponsor's retirement to qualify for
continuous coverage. Family members must have been
enrolled with TRICARE Prime on the sponsor's last day
of active duty orders to qualify for continuous coverage.
TRICARE Select and TRICARE for Life
By enrolling in the Plan, you have agreed to receive your
health care through Johns Hopkins USFHP. DoD has
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Johns Hopkins US Family Health Plan
required as a condition of membership that you agree
not to use TRICARE Select, or TRICARE for Life while a
member of the USFHP.
Membership and Medicare
Oct. 1, 2012 and later Prior to Oct. 1, 2012
Tricare for Life Continued eligibility
in Johns Hopkins USFHP
You may contact Customer Service to verify your
membership effective date.
If you are Medicare-eligible and enrolled in Johns
Hopkins USFHP, your Medicare coverage remains
in effect. However, as a condition of membership,
you have agreed not to use Medicare Parts A and
B or to enroll in a Medicare-sponsored managed
care plan (HMO) such as Medicare Advantage plans
while enrolled with Johns Hopkins USFHP. You are
expected to receive all health care services through
Johns Hopkins USFHP. Using Medicare benefits
while a Plan member may result in disenrollment.
However, you may use Medicare for certain benefits that
are not covered by the Plan.
Contact Customer Service prior to using Medicare for
non-covered benefits to ensure that such use does not
compromise your membership in Johns Hopkins USFHP.
Medicare Part B
When you become Medicare-eligible, you are advised to
enroll in Medicare Part B to avoid penalties or waiting
periods should you choose to leave the Plan and need to
use your Medicare benefits.
Note: Retirees with current Medicare Part B are not
required to pay annual enrollment fees and co-pays
(except for pharmacy).
If You Are About to Become Eligible for Medicare
Benefits
See above for eligibility.
Medicare and Johns Hopkins USFHP
It is important to remember:
• Medicare must not be billed for services covered by
the Plan.
• Members filing Medicare claims or who have claims
filed on their behalf are in violation of the conditions
of participation for the Plan and may be disenrolled.
• Members who have coverage under both the Plan
and Medicare may only use Medicare benefits for
services not covered by the Plan such as chiropractic
care or end-stage renal disease (ESRD).
• For all medical services, Medicare will be billed (as
primary) for members with ESRD.
Enrollment Fees
Eligible retirees, their family members, survivors and
eligible former spouses who do not participate in
Medicare Part B are required to pay an Enrollment fee.
The Enrollment fee is payable at the time of enrollment
into the Plan. Once enrolled, Enrollment fees must be
paid with a credit card or an automatic monthly payment
option. Payment by check is limited to the first quarterly
installment for beneficiaries who elect allotment or
Electronic Fund Transfer (EFT) for the monthly payment
option. Checks, cashier’s checks and/or money orders
can no longer be acceptable forms of payment for
premium fees. You may pay your enrollment fee annually,
quarterly or through monthly allotments or EFT.
Enrollment Fees:
Individual Enrollment:
Group A
$363 annually
$90.75 quarterly
$30.25 monthly
Group B
$438.96 annually
$109.74 quarterly
$36.58 monthly
Family Enrollment:
Group A
$726 annually
$181.50 quarterly
$60.50 monthly
Group B
$879 annually
$219.75 quarterly
$73.25 monthly
Note: TRICARE Prime enrollment fees are subject to
increase each calendar year. Please check Johns Hopkins
USFHP website hopkinsusfhp.org for current fees.
Should you become Medicare-eligible while enrolled
in the Plan and have chosen to pay the enrollment fee
quarterly, please notify the Enrollment Department, and
upon verification of Part B coverage, your portion of
the enrollment fee will be considered paid in full for the
remaining quarter(s).
Annual/Quarterly Payments:
If you choose to pay your enrollment fee on a quarterly
basis, please remember the following:
• When paying enrollment fees on an annual/quarterly
basis, you will receive a bill 30 days prior to your
next annual/quarterly payment due date.
Note: The only acceptable payment is by credit
card.
• Quarterly - after you have been enrolled for three
months, you may request to pay monthly by
allotment or electronic funds transfer (EFT).
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Johns Hopkins US Family Health Plan
• If you fail to make a timely payment, you will be
subject to disenrollment.
Monthly Payments:
Monthly enrollment fees must be paid through an
automated, recurring electronic payment either in the
form of an allotment from retirement pay or through
Electronic Funds Transfer (EFTs) from the enrollee’s
designated financial institution (which may include a
recurring credit or debit card charge). These are the only
acceptable payment methods for the monthly payment
option.
• Enrollees who elect the monthly fee payment option
must pay the first quarterly installment (i.e., the first
three months) at the time the enrollment application
is submitted to allow time for the allotment or EFT
to be established. We shall accept payment of the
first quarterly installment by personal check, cashier’s
check or money order.
Moving with TRICARE Prime
If you are changing TRICARE regions, you can transfer
your enrollment online, by mail (enrollment form) or
telephone. Your enrollment will be effective the date
your request is received or six days from the date the
request is submitted online through Beneficiary Web
Enrollment (BWE).
Split Enrollment
Members of same family may be enrolled in TRICARE in
different regions. Only one region will be for the entire
family enrollment. The sponsor's enrollment determines
which region receives the payment.
• The region where the sponsor is enrolled is the lead
contractor and will bill for the entire family.
• If the sponsor is not enrolled, the region with the
oldest enrolled family member is the lead contractor
and will bill for the entire family.
College Students
Dependent children attending college in another state
(outside The Plan area), should enroll in the region
where they attend college and transfer back into Johns
Hopkins USFHP during the summer to avoid POS
option costs for services obtained outside the service
area.
Disenrollment
As a member of Johns Hopkins USFHP, you will
automatically stay enrolled unless you elect to disenroll
during your annual re-enrollment period.
Important: If your membership with USFHP began on
or after October 1, 2012, you will be disenrolled from
the plan when you become eligible for Medicare.
If you disenroll or become ineligible for the plan, your
coverage ends at midnight on the date you cease to be
an eligible beneficiary, including when you move out of
the area.
Note: Please be aware that Johns Hopkins USFHP
will not be responsible for charges associated with any
service that you receive, including prescriptions, effective
midnight of the date of your disenrollment. This is also
true for retroactive disenrollments.
Automatic Disenrollment
Members may be automatically disenrolled in any of the
following situations:
• Nonpayment of enrollment fees
• Loss of eligibility for military health benefits
• Permanent address outside of USFHP service area
• Members who enrolled in the plan on or after
October 1, 2012, will be disenrolled when they
reach age 65.
Notification of Disenrollment
Upon disenrollment from Johns Hopkins USFHP, you will
receive a Disenrollment Letter from us. It is the member’s
responsibility to notify USFHP within 30 days of receipt of
the letter if you feel you were disenrolled in error.
Other Insurance
Reporting Other Health Insurance is a Plan requirement.
Please call the Coordination of Benefits department at 410-
424-4716 to report any other insurance plans.
Coordination of Benefits
As a DoD-authorized provider of TRICARE coverage,
Johns Hopkins USFHP is committed to preventing
waste of federal resources. One critical way to do this
is by verifying any other health insurance coverage our
members have. Johns Hopkins USFHP and all TRICARE
plans cannot pay any benefit that is payable by another
health plan or health care coverage. Under this law,
as well as clear DoD requirements, if you have other
health care coverage, that coverage must be billed first,
before USFHP is required to provide benefits to you.
Please complete the Other Health Insurance (OHI) form
on our website at hopkinsusfhp.org/members/plan-
documents.
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Johns Hopkins US Family Health Plan
Third-Party Liability and Work-Related
Injury
If you receive care for injuries from an auto accident
or a work-related injury for which a third-party insurer
is responsible for payment, you must inform the
Coordination of Benefits department by calling 410-424-
4716. You should advise the Plan whether or not you
intend to seek compensation. Failure to report this could
result in loss of coverage for care related to this injury.
Insurance Changes
If you change your insurance coverage, or if you obtain
commercial insurance coverage after joining Johns
Hopkins USFHP, you must report it by calling the
Coordination of Benefits department at 410-424-4716.
Marketing and Enrollment Limitations
Johns Hopkins USFHP does not intentionally market
to any beneficiaries with other health insurance (OHI).
If a beneficiary has both USFHP and Federal Employee
Health Benefits Plan (FEHBP), the beneficiary can either
suspend FEHBP or will be treated as a beneficiary
with OHI.
Customer Service
If you would like to get information on benefits and
services, check on the status of a claim or lodge
a complaint with the Complaints and Grievance
department, the Customer Service department will
assist you.
Contact Us
Telephone:
Monday through Friday (8 a.m. - 4:30 p.m.)
410-424-4528
800-808-7347 (toll free)
Fax: 410-424-4895
Assistance for the hearing impaired: Contact
Maryland Relay at 800-201-7165
Write:
Johns Hopkins USFHP
Customer Service Department
7231 Parkway Drive, Suite 100
Hanover, MD 21076
Email:
usfhpcustomerser[email protected]
Internet / HealthLINK Portal:
hopkinsusfhp.org (link under I’m a Member)
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Johns Hopkins US Family Health Plan
Claims and Member
Reimbursements
Members of Johns Hopkins USFHP should never receive
a claim or a bill from a participating provider for a
covered service except for their applicable co-payments.
Participating providers are required to bill the Plan
directly for all covered services provided to members.
If you should receive a claim or a bill in error, email
[email protected] or call the USFHP
Customer Services department at 410-424-4528 or
800-808-7347 and ask the representative to contact the
provider to correct the error.
There is one exception to this policy: If you are
traveling outside the service area and require urgent or
emergency care, the provider should bill the USFHP at
the address shown on the back of your Member ID card.
However, some providers (especially if they are outside
of the United States) may require immediate payment
from you. If so, be sure to obtain a receipt and a copy
of the bill and submit them along with a Reimbursement
Form to the Plan for reimbursement upon your return
Note: Member Reimbursements and all necessary
attachments must be received within 365 days
from the Date of Service (DOS) to be considered for
payment.
Login to your HealthLINK portal, (or create an account
if you don’t have one yet), click “Claims Reimbursement
Form” under the “My Health Plan” tab, click “Member
Reimbursement Form” and fill it out. Be sure to enter in
all the required information and attach proof of payment
information to ensure timely processing. We have also
created a step-by-step guide to help you.
Grievances, Complaints and Appeals
Verbal Complaint Procedure
Johns Hopkins USFHP appreciates member feedback. If
you are dissatisfied with personnel, services or quality
of care, please call Johns Hopkins USFHP Customer
Services, toll-free, at 800-808-7347. All attempts will
be made to resolve the complaint to your satisfaction
during your initial call to Customer Service. If Customer
Service does not resolve your complaint to your
satisfaction, please file a formal grievance. Your formal
grievance will be forwarded
to the Complaints and Grievances Department for
additional investigation.
Written Grievance (Complaint) Procedure
If you wish to register a formal grievance in writing,
please send to the following address:
Johns Hopkins USFHP
7231 Parkway Drive, Suite 100
Hanover, MD 21076
Attn: Complaints and Grievances
Please include a detailed description in your letter,
including dates and names of individuals involved
Grievance (Complaint) Resolution
After receiving your formal grievance, a Complaints and
Grievances representative will notify you of its receipt
and begin appropriate research.
Information regarding the investigation will not become
part of your medical record. However, it is not
always possible to remain anonymous throughout the
proceedings. If Johns Hopkins USFHP is not able to
comply with requests to remain anonymous, this will be
explained to you during the investigation and you will
have the opportunity to withdraw your grievance.
Your complaint will be resolved within 60 calendar
days. If there is no resolution within 30 days, we will
provide a written update to advise the case is still being
investigated. If your complaint is related to the quality
of care rendered by a network provider, the written
response will be limited to confirmation that the case
was investigated because results of the investigation and
associated corrective action steps are confidential and
therefore cannot be shared. If you have any questions
or concerns during the process, please feel free to
discuss with Customer Service or your Complaint and
Grievance representative.
Appeals Procedure
You can appeal certain Johns Hopkins USFHP/TRICARE
Prime decisions. The following issues are subject to
reconsideration (i.e., can be appealed) if you as the
beneficiary and/or your provider are dissatisfied with an
initial denial:
• Medical necessity and appropriateness of the services
furnished or proposed to be furnished
• Appropriateness of the setting in which the services
were or are proposed to be furnished
• A determination regarding benefits under this
program
If you believe that a claim was improperly denied, in
whole or in part, you may file an appeal. Appeals relating
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Johns Hopkins US Family Health Plan
to factual determinations involve issues other than
medical necessity (e.g., whether a service is covered
under TRICARE policy or regulation). Appeals must be
filed in writing within 90 calendar days of the date of
the initial denial determination. Include patient’s name,
address, phone number, Johns Hopkins USFHP I.D.
number, sponsor’s name, and the reason for the appeal
and copies of any other documents related to the issue.
Mail appeal to:
Johns Hopkins USFHP
7231 Parkway Drive, Suite 100
Hanover, MD 21076
Attn: Appeals Department
A request for a reconsideration of a concurrent review
denial (e.g., you, as the patient, are still in the facility)
or a request for an expedited reconsideration of a
preadmission/preprocedure denial must be filed within
a much shorter time. Contact the Customer Service
department at 410-424-4528 or 800-808-7347 for
further details relating to the appeal process.
The TRICARE Quality Monitoring Contractor (TQMC)
is the final appeals level for medical necessity and
appropriateness of care setting.
Customer Service can assist you with the appeal
process. Call 410-424-4528 or 800-808-7347.
Members’ Rights and
Responsibilities
We value you as a member of Johns Hopkins USFHP
family. As a member, you have the following rights and
responsibilities:
You have the right to:
• Be treated with respect for your dignity and privacy.
• Discuss all appropriate treatment options for a
condition regardless of cost or benefit coverage.
• Receive information, including information on
treatment options and alternatives in a manner you
can understand.
• Participate in decisions regarding your health care,
including the right to refuse treatment.
• Be free from any form of restraint or seclusion used
as a means of coercion, discipline, convenience or
retaliation.
• Request and receive a copy of your medical records
and request that they be amended or corrected as
allowed.
• Exercise your rights and to know that the exercise
of those rights will not adversely affect the way that
USFHP or our providers treat you.
• File complaints, appeals and grievances with us.
• Request that ongoing benefits be continued during
appeals (although you may have to pay for the
continued benefits if our decision is upheld in the
appeal).
• Receive a second opinion from another doctor in
USFHP’s network if you disagree with your doctor’s
opinion about the services that you need. Contact
us at 800-808-7347 for help searching for another
doctor.
• Receive other information about us such as how we
are managed. You may request this information by
calling 800-808-7347.
• Receive information about the health plan, its
services, its practitioners, and providers and member
rights and responsibilities.
• Make recommendations regarding the organization’s
member rights and responsibilities policy.
You have the responsibility to:
• Carry your membership card with you at all times
and know your eligibility status with USFHP. If you
lose your card, you can obtain a new one by calling
Customer Service.
• Follow the Plan’s referral and prior-authorization
guidelines and polices.
• Cancel doctor’s appointments if you cannot keep
them.
• Pay any applicable co-pay, coinsurance and
deductible at the time of service.
• Report any other health insurance coverage to your
doctor and to USFHP.
• Report any communicable diseases, family history,
problem with substance abuse, and any other
information your doctor may need in order to
provide adequate care.
• Cooperate with health care providers and follow
plans and instructions for care that you have agreed
to with your practitioners.
• Understand your health problems and participate in
developing mutually agreed-upon treatment goals, to
the degree possible.
30
Johns Hopkins US Family Health Plan
Privacy and Condentiality
It is the policy of Johns Hopkins USFHP to protect the
privacy and security rights of all of its health plan members;
to maintain the confidentiality of Health Plan information
(oral, written, and electronic); and to comply with all
applicable federal and state privacy and security laws and
regulations, including those under the Health Insurance
Portability and Accountability Act (HIPAA).
Information provided to the Plan is kept confidential and
will only be used by the Plan for such purposes as but
not limited to:
• Care Coordination
• Claims processing
• Coordination of benefits with other plans
• Subrogation of claims, review of a disputed claim
• Program integrity activities (examples: investigation
of fraud, waste, abuse, or privacy theft)
• Quality improvement activities
• Other health care operations and/or payment
purposes
To ensure responsible maintenance of your Protected
Health Information (PHI), the Plan has implemented
internal policies and procedures to address how we
further protect, secure and limit use and disclosure
of your oral, written, and electronic health Plan
information. USFHP verifies the identities of both the
member and requestor prior to responding to a request
for a member’s PHI. Examples of such contact include
but are not limited to:
1. Questions about your care management or payment
activities
2. Requests to look at, copy, obtain or amend your
plan records
3. Requests to obtain a list of plan disclosures of your
health information
The Plan secures and limits access to hardcopy and
electronic files. Electronic data is password protected.
Internal controls are in place to ensure that only those
workforce members with a “need to know” have access
to information required to perform their specific job
functions. All workforce members are required to
only utilize and/or access the “minimum necessary”
information to perform their assigned tasks.
For additional information regarding your privacy rights,
please see your notice of privacy practices. If you don’t
have one you may obtain a copy by calling Customer
Service at 800-808-7347 or 410-424-4528. You can
also find a copy on our web site at https://www.
hopkinsusfhp.org/wp-content/uploads/2018/02/
privacy-policy.pdf.
Fraud and Abuse
Johns Hopkins USFHP wants to find and stop health
care fraud. Fraud is any dishonest act that results in a
benefit to the person doing the act or someone else that
he or she is not entitled to. Some examples of health
care fraud are:
• Using someone else’s USFHP insurance card to get
health care services.
• Loaning your USFHP insurance card to another
person so that they can receive health care services.
• Selling prescription medicine or items provided to
you under the USFHP.
• Forging or changing prescription forms.
• Receiving bills for equipment or services you never
received.
As a member you can help reduce health care
fraud by following these simple rules:
• Never loan your USFHP insurance card to anyone.
• Report all suspicions of fraud.
• Report lost or stolen insurance cards to the USFHP
Customer Service Department at 800-808-7347 or
410-424-4528.
For additional assistance, members can call 877-WE
COMPLY (932-6675) to report fraud, waste, and abuse.
Johns Hopkins USFHP Program and Payment Integrity
investigates all charges of actual or suspected health care
fraud. Reporting is simple. To contact Johns Hopkins
USFHP Program and Payment Integrity:
Call: 410-424-4971
Write: JHHC Program and Payment Integrity
Attn: Fraud, Waste and Abuse
7231 Parkway Dr., Suite 100
Hanover, MD 21026
E-mail: [email protected]
Fax: 410-424-2708
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Johns Hopkins US Family Health Plan
Definition of Terms
Attending Physician
The physician who is primarily responsible for
your care in an inpatient hospital setting.
Authorized Services
Those services authorized by the Plan to be
provided to you, upon recommendation by your
primary care manager (PCM).
Catastrophic Cap
An upper limit on out-of-pocket expenses placed
on Johns Hopkins USFHP covered prescription
and medical bills. Dental charges under United
Concordia’s Dental Value Network do not count
toward these caps.
Contractor(s)
Johns Hopkins USFHP programs or Managed
Care Support Contractors.
Co-Payment
The fee you are required by law to pay at the
time of service.
Custodial Care
Care provided by the non-medically skilled,
mainly to help patients with activities of everyday
living.
Defense Enrollment Eligibility
Reporting System (DEERS)
The worldwide computerized Military Health
System that lists all Uniformed Services
beneficiaries. Active-duty members are listed
automatically.
Dependent
The spouse, eligible child, adult disabled child,
or parents of a military sponsor deemed to be
entitled to military benefits as determined by
military regulations.
Durable Medical Equipment
Medical equipment such as wheelchairs, hospital
beds, oxygen, and respirators. Covered when
medically necessary and arranged by the Plan.
Eligible Person
A Military Health System (MHS) beneficiary who
remains eligible in DEERS. See DEERS.
Emergency
Sudden and unexpected onset of life-, limb-, or sight-
threatening conditions requiring immediate medical
attention.
Enrollee
A Uniformed Services beneficiary who voluntarily
and affirmatively seeks and is accepted for
enrollment in the Plan. Eligibility for enrollment in
the Plan is based on eligibility for military health care
benefits, as indicated in DEERS.
Enrollment Period
The period of time during which enrollees agree to
receive covered services solely under the Plan. In
general, each enrollment period is 12 months.
Inpatient
A person treated overnight in a hospital as a
registered bed patient incurring a charge for room
and board, upon the recommendation of a physician.
Managed Care Support Contractor
(MCSC)
The civilian contractor designated by DoD
to operate TRICARE in a particular region in
partnership with the MTFs. The MCSC for Region 1
North is Health Net Federal Services.
Medically Necessary
Services that are (1) provided for the diagnosis
or care and treatment of a medical condition as
determined by a physician; (2) appropriate and
necessary for the symptoms, diagnosis or treatment
of a medical condition; and (3) within standards of
medical practice recognized within the local medical
community.
MHS
Military Health System.
Outpatient Care
Outpatient care includes diagnostic and treatment
services, supplies, and medicines provided and used
at a hospital or other covered facility under the
direction of a physician.
32
Johns Hopkins US Family Health Plan
Plan
Johns Hopkins USFHP as presented in this
document.
Primary Care Manager (PCM)
Each Johns Hopkins USFHP member has a
primary care manager who knows the member’s
medical history, provides most of the member’s
health care, writes referrals for and monitors
any specialist care or tests that are necessary
and helps the member prevent medical problems
in the future. USFHP primary care managers
specialize in internal medicine, family practice or
pediatrics.
Provider
A health care professional, institution, facility or
agency licensed by the appropriate authority and
operating according to law, including a hospital,
physician, doctor of podiatry (D.P.M.), licensed
clinical psychologist (Ph.D.), certified nurse
practitioner, physicians assistant, certified nurse-
midwife, or mental health counselor.
Qualifying Life Event
A status change that includes marriage, divorce,
birth or adoption of a child, relocation outside
of the service area, or loss of eligibility or losing
or gaining Other Health Insurance. A QLE for one
member means that all family members may make
changes within 90 days of the QLE.
Referral
A formal recommendation from a PCM that
directs an enrollee to receive health care services
from another specified care provider. Entitlement
to such services shall not exceed the limits of the
referral and is subject to all terms and conditions
of the group contract.
Room and Board
Charges made by a hospital or other covered
institution for the cost of a room, general-
duty nursing care, and other services routinely
provided to all inpatients, not including special
care units.
Semi-Private Charge
The charge made by a hospital for a room
containing two (2) or more beds, but not including
the charge made by the hospital for special care
units.
Service Area
Johns Hopkins USFHP service area includes the
zip codes in the geographic service area approved
by DoD. Moving outside the service area is a valid
reason to disenroll from the Plan.
Skilled Nursing Facility (SNF)
An institution that meets all the following
requirements: (1) is licensed by the appropriate
public authority as a skilled nursing facility, (2)
is accredited in whole or in a specific part as a
skilled nursing facility for the treatment and care
of inpatients, (3) is engaged mainly in providing
skilled nursing care under the supervision of a
physician in addition to providing room and board,
and (4) is a freestanding or a designated unit of
another licensed health care facility.
Split Enrollment
Refers to multiple family members enrolled in
TRICARE Prime under different Lead Agents/
contractors, including Managed Care Support
(MCS) contractors and Johns Hopkins Uniformed
Services Family Health Plan (USFHP) designated
providers.
TRICARE Prime
This benefit provides the most comprehensive
coverage for health care benefits at the lowest
cost. Each member has a primary care physician
who manages all the individual’s health care.
Johns Hopkins USFHP Member Card
The card issued by the Plan, identifying a military
beneficiary as a member of Johns Hopkins USFHP.
It includes important benefit and compliance
information. This card should be kept with you at all
times.
Johns Hopkins US Family Health Plan
7231 Parkway Drive, Suite 100
Hanover, MD 21076
www.hopkinsusfhp.org
The information contained in this booklet is subject to certain terms, conditions,
and limitations and is not intended as a complete description of Plan benefits.
“TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.”
May 2024
