Table Test
2017 Plan Year Annual Enrollment Fee
| Active-Duty Family Members and/or those with Medicare Part B | Retirees and Family Members without Medicare Part B |
| $0 | $292.60/Individual $565.20/Family |
Covered Services
When provided or authorized by a network provider
| Active-Duty Family Members and/or those with Medicare Part B | Retirees and Family Members without Medicare Part B | |
| Annual Physical (all ages) | $0 | $0 |
| Annual comprehensive GYN exam | $0 | $0 |
| Other doctor visits, including specialists | $0 | $12 |
| Emergency room visits (network or non-network) | $0 | $11/day ($25 minimum) |
Mental Health
When provided or authorized by a network provider
| Active-Duty Family Members and/or those with Medicare Part B | Retirees and Family Members without Medicare Part B | |
| Outpatient Visits | $0 | $12/individual $12/day |
| Partial Hospitalization for mental health / substance abuse | $0 | $12/day |