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The RAUS Group TRICARE
Prime Supplement
Plan
(The Prime Supplement Plan A and B are not available in NC and ND. Plan B is
not available in FL, VT and IA.)
What is TRICARE Prime and Why do I
Need a TRICARE Prime Supplement?
TRICARE Prime is the DoD’s “managed care” health care program for
the military community. It is modeled after the Civilian Health Maintenance
Organization approach (HMO). The two TRICARE Prime
Supplement Plans available to you are de signed to help pay your
cost share and copayments under TRICARE
(In-Network and Out-of-Network expenses).
Enrollment in the
TRICARE Prime Supplement Plan provides
you and your eligible family members with flexibility in converting your
coverage should you move out of a TRICARE Prime area and then apply for a
TRICARE Standard/Extra Supplement. When
this happens, under the TRICARE Standard/ Extra Supplement Plan, you receive
credit towards the Pre-Existing Condition Provision for the time spent in
the TRICARE Prime Supplement Plan.
Eligibility
Retired RAUS members and
spouses, under age 65, who are currently enrolled in TRICARE PRIME, are
eligible to apply for any one of the two supplemental plans described in
this brochure. Unmarried dependent children under age 21(23 if full-time
college student) are also eligible to enroll.
Coverage is also available to eligible
surviving spouses, who are en rolled in TRICARE PRIME.
Termination
Your coverage under the Policy will cease on the first
to occur of:
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1) the date the Policy terminates;
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 you cease
to be a Member of the Policyholder;
4) the first day of the month on or next following the date you cease
to be eligible for the Plan under which he or she is covered;
5) the date we or the Policyholder cancel coverage for a Class of Eligible Person
to which you belong;
6) the date the you attain age 65;
7) the date you cease to be covered under TRICARE;
8) the date you become eligible for Medicare
unless you reside in an area where Medicare is not available, in
which case coverage will not terminate until you return to
residency in an area where Medicare is available. Termination of
coverage will be without prejudice to any claim which originated
before the effective date of termination. |
Exclusions
The Policy does not cover:
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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 Colorado and
Missouri while sane);
4. routine physical exams and immunizations, except when: (a) rendered to a
child up to 6 years from the child’s birth; or (b) ordered by a Uniform
Service: (1) for a Covered Spouse or Child of an Active Duty Member; (2) for
such spouse or child’s travel out of the United States due to your
assignment;
5. domiciliary or custodial care;
6. eye refractions and routine eye exams except when rendered to a child up
to 6 years from the child’s birth;
7. eyeglasses and contact lenses;
8. prosthetic devices (except that artificial limbs and eyes and devices
which must be implanted by surgery are covered);
9. cosmetic procedures, except those resulting from 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
or the care is received by an Active Duty Member’s child who is covered by
the “Program for the Handicapped” under TRICARE;
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 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 the child’s birth;
18. expenses in excess of the TRICARE Cap;
19. expenses which are paid in full by TRICARE;
20. any expense or portion thereof applied to the TRICARE Outpatient
Deductible;
21. treatment for the prevention or cure of alcoholism or drug addiction
except as specifically provided under TRICARE;
22. any part of a covered expense which the Covered Person is not legally
obligated to pay because of payment by a TRICARE alternative program;
23. 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, subject to the Pre-Existing Condition
Limitation. |
Effective Date
Your coverage and that of your covered dependents
becomes effec tive 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.
Deferred Effective Date: If on the date
that You are to become covered under the Policy you are confined in a
Hospital, your coverage will be deferred until the first day after You are
discharged.
Deferred Effective Date (Dependent): If on
the date that an Eligible Dependent is to become covered under the Policy he
or she is confined at home, in a Hospital or elsewhere because of injury or
sickness, coverage of such person will be deferred until the first day after
he or she is discharged from the Hospital or place of confinement.
Conversion
If you end your participation in TRICARE Prime
because you leave the network area, you may convert your TRICARE Prime
supplement to a TRICARE Standard/Extra Supplement Plan within 60 days of
disenrollment. Premiums for the TRICARE Standard/Extra Supple ment Plan will
be those then in effect at time of conversion an Pre-Existing Condition
Limitation will be credited for the period of time covered by the TRICARE
Prime supplement.
Conversion from the TRICARE Prime supplement to a TRICARE Standard/Extra
supplement is available following disenrollment ft any other reason from
TRICARE Prime (after a minimum of one year. enrollment in TRICARE Prime) and
is subject to satisfaction of the TRICARE Supplement Plan Pre-Existing
Conditions Limitation.
Limitations
Routine newborn and well
baby care, hospital nursery charges for a well newborn, dental care,
treatment for prevention or cure of alcohol ism or drug addiction, and
prosthetic devices are limited to expenses covered by TRICARE PRIME.
INPATIENT treatment for mental, nervous or emotional disorders in excess of
45 days if under age 19, or 30 days if 19 or older, is limited to 90 days
(if approved by TRICARE PRIME) per fiscal year. OUTPATIENT benefits for
mental, nervous or emotional disorders, drug addiction or alcoholism are
limited to a maximum of $500 per fiscal year.
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.
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