How It Works

Here's How The Tricare Extra/Standard Supplement Insurance
Works To Pay What Tricare Extra/Standard Doesn't Pay

Care Required	Tricare Extra/Standard Pays	Your Tricare Extra/Standard Supplement High Option II Plan Pays
Inpatient confinement in civilian hospitals for RETIREES and dependent family members (room, board, supplies and staff services billed by the hospital)	The Tricare Standard/DRG amount (contracted rate for Tricare Extra) minus your cost share.	The lesser of $535/day or 25% of billed amount, not to xceed the Tricare Standard DRG amount (lesser of $250/day or 25% cost share of the contracted rate for Tricare Extra) PLUS 100% of covered excess charges up to the reasonable and customary community standard level. (After you satisfy the fiscal year plan deductible.)
Inpatient confinement in civilian hospitals for RETIREES and dependent family members (doctors, & other inpatient services not billed by the hospital)	75% of the Tricare Standard allowed amount (80% for Tricare Extra) for doctors and other professional services.	Your cost share PLUS 100% of covered excess charges up to the reasonable and customary community standard level.
Inpatient confinement in military hospitals	All but the daily subsistence fee.	The daily subsistence fee.
Outpatient care for RETIREES and dependent family members (office visits, clinics, lab, prescription drugs, etc.)	75% of the Tricare Standard allowed amount (80% for Tricare Extra) after you pay the Tricare Outpatient Deductible.	Your cost share PLUS 100% of covered excess charges up to the reasonable and customary community standard level, AFTER you pay the fiscal year plan deductible of $150 per person, $300 family maximum.
Inpatient confinement in civilian hospitals for ACTIVE DUTY dependents Outpatient care for ACTIVE DUTY dependents (office visits, clinics, lab, prescription drugs, etc.)	All allowable charges except daily subsistence fee or $25, whichever is greater. 80% of the Tricare Standard allowed amount (85% for Tricare Extra) after you pay the Tricare Outpatient Deductible.	Active Duty Plan- $25 or the daily subsistence fee, hichever is greater, PLUS 100% of covered excess charges up to the reasonable and customary community standard level. Active Duty Plan- Your cost share PLUS 100% of covered excess charges up to the reasonable and customary community standard level, AFTER you pay the Tricare Extra Standard Outpatient Deductible.

We will pay the Inpatient and Outpatient covered medical expenses once the fiscal plan deductible of $150 per person and $300 family maximum has been satisfied. Expenses incurred to satisfy the fiscal year TRICARE Standard/Extra Outpatient Deductible cannot be used to satisfy the High Option II Supplemental Plan Deductible.

Confined or Confinement means being an Inpatient in a Hospital (or Skilled Nursing Facility) due to Sickness or Injury.
And Skilled Nursing Facility does not mean:

a) a hospital; or
b) a place for rest, custodial care, or the aged; or
c) a place for the treatment of mental disease, drug addicts or alcoholics.

Economical Quarterly Premiums To Fit Your Budget

As a member you benefit from your organization’s mass purchasing power, making the rates for this valuable coverage more affordable.
What's more, the insurance company guarantees you'll never be singled out for a rate increase, no matter how many claims you file!

Age of Retiree, Spouse, Widow/er, Former Spouse (Premiums shown are per person)	High Option II Plan	Active Duty Plan
Under 40	$ 75
40 - 44	$ 81
45 - 49	$ 90
50 - 54	$ 114
55 - 59	$ 144
60 - 64	$ 159
Each Child* of Retiree	$ 60
Spouse of Active Duty Member	Not Available	$ 21
Each Child* of Active Duty Member	Not Available	$ 18

*Newborn children not named in your enrollment form are automatically covered from birth for injury or sickness, including treatment of congenital defects and birth abnormalities, for 31 days. You must notify the Plan Administrator in writing and pay the additional premium due within 31 days of birth for coverage to continue beyond this period. Insured children who are incapable of self-sustaining employment because of mental retardation or physical disability- and who are unmarried and chiefly dependent on the insured member for support and maintenance—may continue coverage past policy age limits, with a dependent.

Rates are based on the attained age of the insured person and increases as you enter each new category. Rates and /or benefits may be changed based on a class basis.

NOTE: To pay premium semi-annually or annually, just multiply your quarterly premium by 2 or 4 respectively.

Eligibility

You are eligible to enroll provided you are an eligible Tricare/ChampVA recipient, under age 65, and entitled to retired, retainer, or equivalent pay. If you are age 65 or over and ineligible for Medicare, you may apply for the plan by attaching a copy of your Social Security Notice of Disallowance of Benefits to your Enrollment Form.

Coverage is also available for your Tricare eligible spouse under age 65, and dependent, unmarried children under age 21 (23 if in college). Eligible spouses and children of active-duty service members may enroll; Tricare-eligible widow(er)s and ex-spouses may also enroll.

CHAMPVA eligible dependent, unmarried children under age 18 (23 if in college) may also enroll.

Effective Date

Your coverage and that of your covered dependents becomes effective on the first day of the month following receipt of your Enrollment Form and first premium payment. If, on that day, you or a covered dependent are confined in a hospital, the effective date will be the day following discharge from the hospital.

Limitations

Routine newborn and well baby care, hospital nursery charges for a well newborn, dental care, treatment for prevention or cure of alcoholism or drug addiction, and prosthetic devices are limited to expenses covered by Tricare. See coverage information below for mental, nervous, or emotional disorders.

Pre-Existing Conditions Limitations

Any injury or sickness whether diagnosed or undiagnosed, for which a covered person received medical care or treatment within the 6 month period preceding the effective date of his or her insurance will not be covered until the coverage has been in effect for 6 months. However, new conditions will be covered immediately.

Exclusions

injury or sickness resulting from war or act of war, whether war is declared or undeclared;
intentionally self inflicted injury;
suicide or attempted suicide, whether sane or insane (in Missouri, while sane);
the following services: a) routine physical exams, unless required for school enrollment (but not sports physicals) by a Covered Child aged 5 through 11; and b) immunizations; except that these services are covered when rendered to a Covered Child who is less than 6 years of age;
domiciliary or custodial care;
eye refractions and routine eye exams except when rendered to a child up to 6 years from his or her birth;
eyeglasses and contact lenses;
prosthetic devices, except those covered by TRICARE;
cosmetic procedures, except those resulting from covered Sickness or Injury;
hearing aids;
orthopedic footwear;
care for the mentally incapacitated or physically handicapped if the care is required because of the mental incapacitation or physical handicap;
drugs which do not require a prescription, except insulin;
dental care unless such care is covered by TRICARE, and then only to the extent that TRICARE covers such care;
any confinement, service, or supply that is not covered under TRICARE;
Hospital nursery charges for a well newborn, except as specifically provided under TRICARE;
any routine newborn care except Well Baby Care, as defined, for a child up to 6 years from his or her birth;
TRICARE eligible cost-share and deductible amounts in excess of the TRICARE Cap;
expenses which are paid in full by TRICARE;
treatment for the prevention or cure of alcoholism or drug addiction except as specifically provided under TRICARE and the Policy;
any part of a covered expense which the Covered Person is not legally obligated to pay because of payment by a TRICARE alternative program;
any claim under more than one of the TRICARE Supplement Plans, or under more than one Inpatient Benefit or more than one Outpatient Benefit of the TRICARE Supplement Plans. If a claim is payable under more than one of the stated Plans or Benefits, payment will only be made under the one that provides the highest coverage.

Nervous, Mental, Emotional Disorder, Alcoholism, and Drug Addiction Limits

The coverage provided under the Inpatient Benefit of the TRICARE Supplement plan for nervous, mental and emotional
disorders, including alcoholism and drug addiction, is limited to:

a) 30 Inpatient treatment days for a Covered Person age 19 or older; or
b) 45 Inpatient treatment days for a Covered Person under age 19;

per Fiscal Year.
This Inpatient limit is based on the number of days TRICARE normally provides each Fiscal Year for such confinements.

In rare instances, TRICARE extends these daily limits.

If this occurs, we will limit the number of days that we provide for such confinement to the lesser of:

a) the number of days TRICARE pays for such Inpatient treatment during the Fiscal Year; or
b) 90 Inpatient days per Fiscal Year.

The coverage provided under the Outpatient Benefit of the TRICARE Supplement plan for:

a) nervous, mental, and emotional disorders; and
b) alcoholism and drug addiction;

is limited to $500 during any Fiscal Year for all such disorders.

Termination

Insured Person Termination: The Insured Person's coverage under the Policy will cease on the first to occur of:

1) the date the Policy terminates, or the date the Organization ceases to be a Participating Organization of the Policyholder;
2) the date the required premium is not paid, subject to the Grace Period provision;
3) the first day of the month on or next following the date he or she ceases to be a Member;
4) the first day of the month on or next following the date he or she ceases to be eligible for the Plan under which he or she is covered;
5) the date we or the group cancel coverage for a Class of Eligible Person to which he or she belongs;
6) the date the Member attains age 65;
7) the date he or she becomes eligible for Medicare, if under age 65 at time of Medicare eligibility, you must notify ASI in writing.

Termination of an Insured Person's insurance will not prejudice any claim which occurred before the effective date of termination.

Dependent Termination: The dependent's coverage under the Policy will cease on the first to occur of:

a) the date the Policy terminates, or the date the Organization ceases to be a Participating Organization of the Policyholder;
b) the date the required premium is not paid, subject to the Grace Period provision;
c) the first day of the month on or next following the date he
or she ceases to be an Eligible Spouse or an Eligible Child;
d) the first day of the month on or next following the date he or she ceases to be eligible for the Plan under which he or she is covered;
e) the date we or the group cancel coverage for a Class of Eligible Person to which he or she belongs;
f) the date he or she ceases to be covered under TRICARE;
g) the date he or she becomes eligible for Medicare (must notify ASI in writing);
h) the date the Member ceases to be covered, subject to the Covered Dependent’s Continuation Provision; (This will not apply to the Spouse or Child of an Active Duty Member or a Service Disabled Member.)
i) if a Spouse, the date he/she attains age 65.

Termination of a Covered Dependent's insurance will not prejudice any claim which occurred before the effective date of termination.

Non-Duplication of Coverage under Employer Health Program

If a claim payable under the Policy is also payable under an Employer Health Program with TRICARE as the secondary payor, we will limit our payment to an amount which, when added to the amounts paid by the Employer Health Program and TRICARE, will not exceed 100% of TRICARE Covered Expenses.

Guaranteed Acceptance—Satisfaction Guaranteed

It's easy to enroll in the Tricare Extra Standard Supplement Insurance Plan. Just complete the attached Enrollment Form—making sure to provide all information requested—and return it with your check for the first premium payment. That's all there is to it! You cannot be turned down for coverage, although a pre-existing condition may initially limit the extent of your coverage. After your completed Enrollment Form and first premium payment have been processed, you'll receive a certificate of insurance which you can examine for 30 days risk-free. Return it for a full refund if you are not completely satisfied.