• You pay $0 for hospital stay
• You pay $25.00 for emergency room visits
• You pay $10.00 for emergency room visits, when referred by Teleconsulta

• You pay $0 for preventive tests such as CBC, lipid panel, colorectal cancer test, tests for weak bones, PSA test, routine women cancer test, routine breast exams and shots for children and adults.
• You pay $7.50 per office visit to a general doctor
• You pay $10.00 per office visit to a specialist doctor
• You pay $0 in X-rays, MRI, and MRA
• You pay 20% for diagnostic test, non-invasive heart exams
• You pay $0 for Gardasil and Cervarix shots

We cover up to 60 therapies per condition. We may offer coverage for therapies that go beyond the limit if we believe they are needed.

• $10.00 per therapy

We cover maternity benefits, like visits during pregnancy and after giving birth.

• You pay $10 per office visit
• You pay $0 for delivery (natural birth or C-section)
• You pay $0 for manual breast pump

• You pay $0 for inpatient or partial hospitalization
• You pay $7.50 per office visit to a psychiatrist, psychologist, and social workers

Mental Health, Total Health
The mental health program for Federal Employees aims to provide adequate care for mental health conditions and substance abuse, to help improve the overall health of the insured.

The program is available 24 hours a day and includes visits to a psychiatrist, social workers and psychologists, partial and regular hospitalization.

Call 1 (800) 660-4896 or coordinate services through the website: www.fhcsaludmental.com

• Local ambulances are covered at a 100% through reimbursement
• You pay $0 for air ambulance, only in Puerto Rico and US Virgin Islands.

One pair of eyeglasses or contact lenses a year for members up to age 21 from selected Network providers, you pay nothing up to the fee.

• Generic Drugs: You pay $0 per unit or refill (30 days)
• Preferred Brand Drugs: You pay $20 per unit or refill (30 days)
• Non-Preferred Brand Name Drugs: You pay 20% or $20, whichever is higher, up to $125 per unit or refill (30 days)
• Preferred Specialty Drugs: You pay 25% or $200, whichever is the lowest, per unit or refill. Only through certain specialty drug stores.
• Non Preferred Specialty Drugs: You pay 30% or $300, whichever is the lowest, per unit or refill. Only through certain specialty drug stores.

Drug Cost Calculator

By using the Drug Cost Calculator you can see an estimate of how much you will pay for your covered medicine, and learn about the different treatments for you under your plan.

*Disclaimer
These prices show the most current cost information, but sometimes it will not necessarily be the same as the real cost. These estimated drug prices could change. There is an amount that the member must pay to get the medicine, and it depends on the pharmacy coverage.

This may mean a fixed amount or percentage of the price. It will be based on the rate of the plan for each prescription. To get the amount, the maximum number of day supply and what is normally dispensed is used. This is why it may not show the prescribed dose.

Flex 90 Program

Is a voluntary program that allows the member to get a 90-day supply of some medicines at retail drug stores that are part of the program. To get it, follow these steps:

1. Ask your doctor for a 90-day prescription plus one (1) refill of your medicines
2. Select a particular pharmacy from the Flex 90 Program
3. Ask your pharmacist for a 90-day amount

This basic dental coverage offers you benefits such as:

• You pay $0 for cleanings for children and adults (one (1) every six months)
• You pay $0 for mouth and bitewings x-rays
• You pay 30% for panoramic x rays (one (1) group every 3 years)
• You pay 30% for amalgam restorations, endodontics, extractions and mouth surgery

We cover medical emergencies and pre-authorized services only. When you get covered services outside the area that are neither emergency nor preauthorized, we will pay back 90% of Triple-S Salud’s established fees, after any copay or coinsurance that applies. You are responsible up to the billed charges for these services.

Oral checks, cleanings, tests that show images of the mouth, coating used to protect teeth, and more.

Procedures to strengthen, crowns, deep cleanings, denture adjustments, tooth pulling, and more.

Care for the interior of the tooth and other parts of the mouth, and services such as crowns, dentures, and bridges. For some major care, you will pay 30% of the total cost.

It covers up to $2,000 per member per lifetime. If you are a new member, you must wait 12 months to get services, but there is no age limit.