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USBA TRICARE Standard/Extra Supplement Plan

USBA High Option II Plan - USBA’s Supplement to TRICARE Standard and TRICARE Extra.

You Pay:

  • The TRICARE Standard/Extra Supplement Plan’s fiscal year deductible of:
    • $250 per person or $500 per family.
    • Active duty military do not have an annual deductible.
  • The TRICARE Standard/Extra Fiscal year outpatient deductible.

USBA High Option II pays:

  • Your daily subsistence for inpatient confinement in military hospitals.
  • Your cost share for inpatient confinement in civilian hospitals.
  • Your cost share for outpatient confinement after the TRICARE outpatient deductible has been met (25% of TRICARE Standard allowed amount).
  • 100% of covered excess charges up to the legal limit.

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 for the plan by attaching a copy of your Social SecurityNotice: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 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.

Effective May 1, 2011, the TRICARE Supplement Plan will provide supplemental coverage for dependent 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 be enrolled in TRICARE Young Adult before enrolling in the TRICARE Supplement Plan. TYA coverage ends if any of the following occurs:

- Dependent attains age 26 - Gets married - Becomes eligible for an employer-sponsored plan - Gains other TRICARE coverage

- Sponsor ends TRICARE coverage

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.

Termination - The Insured Person’s coverage under the Policy will cease on the first to occur of: the date the Policy terminates, or the date the Organization ceases to be a Participating Organization of the Policyholder; the date the required premium is not paid, subject to the Grace Period provisions; the first day of the month on or next following the date he or she ceases to be a Member; 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; the date we or the group cancel coverage for a Class of Eligible Persons to which he or she belongs; the date he or she attains age 65; the date he or she becomes eligible for Medicare. Termination of an Insured Person’s insurance will not prejudice any claim which occurred before the effective date of termination.

The dependent’s coverage under the Policy will cease on the first to occur of: the date the Policy terminates, or the date the Organization ceases to be a Participating Organization of the Policyholder; the date the required premium is not paid, subject to the Grace Period provision; 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 (except that a spouse who remains eligible for TRICARE after divorce or legal separation from the Member may continue his or her coverage until he or she remarries, subject to payment of the required premium); 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; the date we or the group cancel coverage for a Class of Eligible Persons to which he or she belongs; if a Spouse, the date he or she attains age 65; the date he or she becomes eligible for Medicare; the date the Member ceases to be covered, subject to the Covered Dependent Continuation provision, (this will not apply to the Spouse or Child of an Active Duty Member or a Service Disabled Member); if a Child, the date he or she attains age 21 or age 23 if he or she is enrolled full time at a school of higher learning. Termination of a Covered Dependent’s insurance will not prejudice any claim which occurred before the effective date of termination.

Exclusions - This 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, whether sane or insane (in Colorado and Missouri, while sane); routine physical exams and immunizations, except when: rendered to a child up to

6 years from his or her birth; or ordered by a Uniformed Service: for a Covered Spouse or Child of an Active Duty Member; or for such spouse or child’s travel out of the United States due to Member’s assignment; domiciliary or custodial care; eye refractions and routine eye exams except when rendered to a child up to 6 years from his or her birth; eyeglasses and contact lenses; prosthetic devices, except those covered by TRICARE; cosmetic procedures, except those resulting from Sickness or Injury while a Covered Person; hearing aids; orthopedic footwear; 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; drugs which do not require a prescription, except insulin; dental care unless care is covered by TRICARE, and then only to the extent that TRICARE covers such care; any confinement, service, or supply that is not covered under TRICARE; Hospital nursery charges for a well newborn, except as specifically provided under TRICARE; any routine newborn care except Well Baby Care, as defined, for a child up to 6 years from his or her birth; expenses in excess of the TRICARE Cap; expenses which are paid in full by TRICARE; any expense or portion thereof which is in excess of the Legal Limit; the part of any Covered Expense which is in excess of the TRICARE Allowed Amount except as otherwise stated in the Supplement Benefits; treatment for the prevention or cure of alcoholism or drug addiction except as specifically provided under TRICARE and the 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; and 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 Plan.

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 Limitations.

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. The coverage provided under the Inpatient Benefits of the TRICARE Supplements for nervous, mental and emotional disorders, including alcoholism and drug addiction, is limited to: 30 Inpatient treatment days for a Covered Person age 19 or older; or 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: the number of days TRICARE pays for such Inpatient treatment during the Fiscal Year; or 90 Inpatient days per Fiscal Year. The coverage provided under the Outpatient Benefits of the TRICARE Supplements for: nervous, mental, and emotional disorders; and alcoholism and drug addiction; is limited to $500 during any fiscal year for all such disorders.

*Pre-Existing Condition Limitations - Pre-Existing Condition, as used in this limitation, means any injury or sickness including pregnancy, diagnosed or undiagnosed, for which Medical Care is received by a Covered Person; within the 6 month period prior to the Covered Person’s effective date of insurance; or with respect to the limitation for increase in coverage, within the 6 month period prior to the effective date of the Covered Person’s increase in coverage. For the purposes of this limitation, we will consider; (a) Medical Care received when: a Physician is consulted or medical advice is given; or Treatment is recommended or prescribed by, or received from, a Physician; (b) Treatment to include, but not limited to, any; medical examination, test, attendance, or observation; medical services, supplies, or equipment, including their prescription or use; or prescribed drugs or medicines, including their prescription or use. All manifestations, symptoms, or findings which result; from the same or related accidents or Sickness; or from any aggravations of accident or Sickness; are considered to be the same accident or Sickness for the purpose of determining a Pre-Existing Condition.

Waiver for Conditions Prior to Effective Date of Coverage: Under the following conditions, the period of time required to satisfy the Pre-Existing Condition exclusion will be reduced or waived as stated:

If you retire from Active Duty and become eligible for TRICARE Retiree Supplement coverage as provided under “Plan Conversions” and Requests such coverage within 63 days of the date you first becomes eligible for coverage, we will credit you with continuity of coverage from your prior effective date under the TRICARE Supplement Plan.

This site explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of any discrepancy between this site and the contract, the terms of the contract will apply. Complete details are found in the certificate of insurance issued to each insured individual. This program may not be available to residents of all states. You will be notified by the Administrator if you are ineligible for coverage.

AT#1071971

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