Exclusions and Limitations Apply To Your TRICARE Supplement Coverage
Who Is Eligible for Coverage?
Active Duty Family Plan
Your spouse (under age 65) and unmarried dependent children under age 21 (age 23 if a full-time student) are eligible for coverage. All family members must be covered by TRICARE.
TRICARE Reserve Select Supplement Plan
You, your spouse (under age 65) and unmarried dependent children under age 21 (age 23 if a full-time student) are eligible for coverage. All family members must be covered by TRICARE Reserve Select and cannot be eligible for Federal Employees Health Benefits Program (FEHBP) or currently covered under FEHBP.
You, your spouse (under age 65) and unmarried dependent children under age 21 (age 23 if a full-time student) are eligible for coverage. All family members must be covered by TRICARE.
TRICARE Prime A and B Supplement Plans
You, your spouse (under age 65) and unmarried dependent children under age 21 (age 23, if a full-time student) are eligible for coverage. All family members must be covered by TRICARE.
When Does Coverage Start And End?
Effective Date of Coverage
Your coverage will become effective on the first day of the month following the date your enrollment form is received. If you are confined in a hospital on the date you are to become covered under the policy, your coverage will be deferred until the first day after you are discharged.
Your coverage will remain in effect as long as you continue to pay your premiums when due, the group policy remains in force, and you remain eligible for coverage. Your coverage ends when you become eligible for Medicare, or you reach age 65 (unless you are not eligible for Medicare).
Extension of Benefits for Total Disability
If a covered person is Totally Disabled on the date his or her coverage ends, TRICARE supplement coverage will extend inpatient benefits until the date he or she is no longer Totally Disabled; or 90 days from the date his or her Inpatient Benefit ended, whichever is the first to occur. Outpatient Benefits under the Plan will continue up to 90 days from the date of termination. The continuation will only apply to expenses incurred for the injury or sickness that caused the total disability.
Pre-Existing Conditions Limitation
Any injury or sickness, whether diagnosed or undiagnosed for which any person proposed for coverage has received medical treatment or care within 6 months immediately preceding their effective date will not be covered (a) until that person has not received medical treatment or care for that condition during a period of 6 consecutive months (ending any time on or after the covered person’s effective date) or (b) until the coverage has been in effect for 6 months. New conditions will be covered immediately.
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, whether sane or insane
- routine physical exams and immunizations, except when:
a. rendered to a child up to 6 years from his or her birth; or
b. 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;
- domiciliary or custodial care;
- eye refractions and routine eye exams except when rendered to a child up to 6 years from the child's 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:
a. the care is required because of the mental incapacitation or physical handicap; or
b. 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 such 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 applied to the TRICARE Outpatient Deductible;
- that part of any Covered Excess Charges 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 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.
This material explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this brochure and the contract, the terms of the contract apply. Complete details are in the Certificate of Insurance issued to each insured individual.
This program is not available in all states.
TRICARE Form Series includes Form GBD-3000 (2017); Form GBD-3100 (2017) or state equivalent.
This website explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this brochure and the policy, the terms of the policy apply. All benefits are subject to the terms and conditions of the policy. Policies underwritten by Hartford Life and Accident Insurance Company Hartford Life Insurance Company detail exclusions, limitations, and terms under which the policies may be continued in full or discontinued. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy issued to the policyholder. This program may vary and may not be available to residents of all states.
How to Enroll
- Download and print the Enrollment Form for this plan.
- Send the completed Enrollment and initial payment to:
AFA Plan Administrator
P.O. Box 14464
Des Moines, IA 50306