|Care Required||TRICARE Standard/Extra Pays||Your TRICARE Standard/Extra 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 exceed the TRICARE Standard DRG amount (lesser of $250/day or 25% cost share of the contracted rate for TRICARE Extra) AFTER you satisfy the fiscal year plan deductible PLUS 100% of covered excess charges up to the Legal Limit.)|
|Inpatient confinement in civilian hospitals for RETIREES and dependent family members (doctors, and 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 AFTER you satisfy the **fiscal year plan deductible PLUS 100% of covered excess charges up to the Legal Limit.|
|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 AFTER you satisfy the fiscal year plan deductible PLUS 100% of covered excess charges up to the Legal Limit. For prescription drugs - the plan pays your copayment amounts.|
|Inpatient confinement in civilian hospitals for ACTIVE DUTY dependents|
Outpatient care for ACTIVE DUTY dependents (office visits, clinics, labs, 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, whichever is greater.
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.*
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**Legal Limit means the maximum amount that a non-participating provider can legally charge. This amount is up to the 115% of the TRICARE Allowed Amount.
You are eligible to enroll if you are a TRICARE eligible recipient, under age 65, and entitled to retired (Military), 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. If you are:
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.
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.
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.
For individuals who are newly retired from active duty military and who enroll in the plan within 63 days of the military retirement date. Application for coverage should include a copy of their DD-214.
For individuals who were previously enrolled in a non-TRICARE Supplement Employer Group Plan and loses that coverage due to involuntary termination. Such individuals must enroll in the Supplement Plan within 31 days following the termination date of the prior insurance plan. Application for coverage under the Supplement Plan should include a copy of the Certificate of Creditable Coverage for the prior group insurance plan.
The Plan is currently not available in CO, ME, NH, OR, WA.