(You must be enrolled in TRICARE Prime to apply for one of the following plans)
The Plan Pays
(point of Service Option)
The Plan pays
|Plan A||Your eligible TRICARE Prime copayments and cost shares up to the TRICARE Prime catastrophic limits.||Nothing||The Point of Service (POS) deductible ($300) your 50% cost share for Out-of-Network charges in excess of the TRICARE allowed amount.|
|Plan B||Your eligible TRICARE Prime copayments and cost shares up to the TRICARE Prime catastrophic limits.1||Your 50% of the TRICARE Allowed amount (your cost share) for In-Patient charges after you pay the Point of Service deductible.||The Point of Service ($300) deductible and charges in excess of the TRICARE allowed amount|
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Retired GEA 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 enrolled in TRICARE PRIME.
Your coverage under the Policy will cease on the ﬁrst to occur of:
The Policy does not cover:
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.
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.
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 Supplement Plan will be those then in effect at time of conversion and the 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 for 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.
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.
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 insur¬ance will not be covered until the coverage has been in effect for 6 months. However, new conditions will be covered immediately
The Plan is currently not available in CO, ME, NH, NV, OR, WA.