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The RAUS Group Tricare Supplement
Available to all CHAMPUS/CHAMPVA eligible recipients
(E-1 through O-10) regardless of service!
Get the protection you need a a price you can
afford.
The TRICARE Extra, Standard
Supplement High Option II Plan provides benefits to help pay your
TRICARE cost share for in-hospital and outpatient care, doctor visits,
emergency room care, prescription medications, and much more.
The High Option II Plan also pays 100% up to the legal
limit, not
the 115% legal limit cap imposed by Tricare.
The High Option plan has a fiscal year Plan Deductible
of $250 per person and $500 family maximum.
There is also a plan for Dependents of Active Duty
Members.
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
The Policy does not cover:
1. injury or sickness resulting from war or act of war, whether war is
declared or undeclared;
2. intentionally self inflicted injury;
3. suicide or attempted suicide, whether sane or insane (in Missouri, while
sane);
4. 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;
5. domiciliary or custodial care;
6. eye refractions and routine eye exams except when rendered to a child up
to 6 years from his or her birth;
7. eyeglasses and contact lenses;
8. prosthetic devices, except those covered by TRICARE;
9. cosmetic procedures, except those resulting from covered Sickness or
Injury;
10. hearing aids;
11. orthopedic footwear;
12. care for the mentally incapacitated or physically handicapped if the
care is required because of the mental incapacitation or physical handicap;
13. drugs which do not require a prescription, except insulin;
14. dental care unless such care is covered by TRICARE, and then only to the
extent that TRICARE covers such care;
15. any confinement, service, or supply that is not covered under TRICARE;
16.Hospital nursery charges for a well newborn, except as specifically
provided under TRICARE;
17. any routine newborn care except Well Baby Care, as defined, for a child
up to 6 years from his or her birth;
18. TRICARE eligible cost-share and deductible amounts in excess of the
TRICARE Cap;
19. expenses which are paid in full by TRICARE;
20. treatment for the prevention or cure of alcoholism or drug addiction
except as specifically provided under TRICARE and the Policy;
21. any part of a covered expense which the Covered Person is not legally
obligated to pay because of payment by a TRICARE alternative program;
22. 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. |
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To download and print the complete insurance plan,
coverage, rates and necessary forms (including the RAUS Membership
Application) in Adobe Acrobat PDF format,
click here. |
To download/view Pre-Existing Condition Plan
Enhancements (Effective October 1, 2004) in the Adobe Acrobat PDF format,
click here. If you do not have the
current Acrobat Reader software, you may obtain it FREE
from Adobe's web site. Click on the following link
to go there.
For more about Tricare Supplement Insurance, select:
[ The Plan | Coverage |
Group Rates |
About Us |
Enrollment ]
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