TRICARE Prime

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 en­rolled in TRICARE PRIME.

Termination

Your coverage under the Policy will cease on the first to occur of:

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 you are covered;
5. The date we or the Policyholder cancel coverage for a Class of Eligible Person to which you belong;
6. The date 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:

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:
   • Rendered to a child up to 6 years from his or her birth
   • Ordered by a Uniformed 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 the Member’s assignment
5. Domiciliary or custodial care
6. Eye refractions and routine eye exams except when rendered to a child up to 6 years from his or her 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 while a Covered Person
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 a 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 his or her 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. 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 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 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.

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 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.

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 Limitation

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