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The RAUS Group TRICARE Supplement
Plan
Available to all TRICARE eligible recipients
(E-1 through O-10) regardless of service!
(This product is currently unavailable in ME, MT, NH and VT)
 Get the protection you need at a price you can
afford.
The TRICARE Standard/Extra
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% of Covered
Excess Charges up to the Legal Limit.
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.
TRICARE Young Adult (TYA) Program
TRICARE Young Adult (TYA) is a “premium-based
health care plan available for purchase” by qualified adult children, under
age 26, after their eligibility for regular TRICARE ends. TYA offers TRICARE
Standard coverage and includes medical and pharmacy benefits.
For further information on TRICARE Young Adult, please
visit the TRICARE web site at
www.tricare.mil/tya.
Effective May 1, 2011, the TRICARE Supplement Plan will
provide supplemental coverage for dependents enrolled in TYA.
These young adult dependents will have the same
supplement plan premium rates, benefits and coverage limitations as
dependent children under the age of 21 or 23 if full-time student.
To enroll your adult dependent child in the TRICARE
Supplement Plan, complete the enrollment form and mail to ASI along with a
copy of his/her TYA enrollment card.
Your adult dependent child must enroll in TRICARE Young
Adult before enrolling in the TRICARE Supplement Plan. TYA coverage ends if
any of the following occurs:
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Dependent attains age 26
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Gets married
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Becomes eligible for an employer-sponsored plan
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Gains other TRICARE coverage
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Sponsor ends TRICARE coverage
 Eligibility
You are eligible to enroll provided you are an eligible TRICARE 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 enroll in 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.
TRICARE eligible dependent, unmarried children under
age 21 (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:
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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.
Exclusions for
the state of New York
The Policy does not cover injury or sickness resulting from war
or act of war, whether war is declared or undeclared;
intentionally self-inflicted injury; suicide or attempted
suicide; eyeglasses; rest cures; custodial care; eye refractions
and routine eye exams when rendered to a child up to 2 years
(730 days) from the child’s birth; cosmetic surgery, except that
cosmetic surgery shall not include reconstructive surgery when
such surgery is incidental to or follows surgery resulting from
trauma, infection, or other diseases of the involved part, and
reconstructive surgery because of a congenital disease or
anomaly of a covered dependent child which has resulted in a
functional defect; hearing aids; dental care or treatment,
except for such care or treatment due to accidental injury to
sound natural teeth within 12 months of the accident and except
for dental care or treatment necessary due to congenital disease
or anomaly; any confinement, service, or supply that is not
covered under TRICARE; TRICARE eligible cost-share and
deductible amounts expenses in excess of the TRICARE Cap except
as specifically provided; expenses in excess of the TRICARE
Allowed Amount except as
specifically provided; expenses which are paid in full by
TRICARE except as specifically provided; any expense or portion
thereof applied the TRICARE Outpatient Deductible except as
specifically provided; treatment for the prevention or cure of
alcoholism or drug addiction except as specifically provided
under TRICARE and this 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, subject to the
Pre-Existing Condition Limitation.
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.
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Termination
Insured Person Termination:
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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
Certificate
will cease on the first to occur of:
a) the date the Certificate 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.
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Non-Duplication of Coverage under
Employer Health Program
If a claim payable under the Certificate, it 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.
Change of Policy Premiums
We have the right on each Premium Due Date to change the rate at which
premiums will be calculated. This includes the right to change premium
rates for a benefit that applies to all individuals of the same class,
age, plan and effective date. Rates may be changed based on claims
experience of the Policy. We will give the Policyholder or Organization
notice of any change at least 45 days before the Premium Due Date on
which it is to become effective.
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Guaranteed Acceptance
- Satisfaction Guaranteed
It's easy to enroll in the TRICARE
Standard/Extra Supplement Plan. Just complete the
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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