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Get the protection you need, at a price you can afford.
The TRICARE Extra, Standard Supplement gives you the choice of
two options: the Comprehensive Plan or the High Option II Plan. Both
options provide benefits to help pay your TRICARE cost share for in-hospital
and outpatient care, doctor visits, emergency room care, prescription
medications, and much more.
Both options also pay 100% of covered excess charges up to the reasonable
and customary standard level. You are not limited to the 115% legal limit
cap imposed by Tricare. The Comprehensive Plan has a new survivor benefit
that pays the premium for the surviving spouse and covered dependents up
to one year.
The High Option plan has a fiscal year Plan Deductible of $150 per person
and $300 family maximum and does NOT reimburse the Tricare deductible.
The Comprehensive Plan reimburses the TRICARE fiscal year outpatient
deductible subject to a modest fiscal year Plan Deductible of $75 per
person and $150 per family.
There is also a plan for Dependents of Active Duty Members. See Benefit chart.
It's Very Easy To Enroll: Just
Click here to fill out the Online Application form.
Eligibility
You are eligible to enroll provided you are an eligible TRICARE or CHAMPVA
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 apply for the
plan by attaching a copy of your Social Security Notice 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.
Waiver of Premium for Surviving Spouse and Dependents
The Comprehensive Plan features a special benefit that provides additional
financial protection to your surviving spouse and dependents. If you die
while insured under the Plan, your insured spouse's and/or dependents premiums will be waived
for up to 4 years unless your spouse remarries, reaches 65, or dependents
no longer remain in an eligible status. After 4 years, he or she will need to
begin paying the appropriate premium to continue coverage.
Effective Date
Your coverage and that of your covered dependents become 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.
Renewability
Your coverage is renewable to age 65 as long as premiums are paid on time;
you remain a member of the sponsoring organization; you, your spouse and
dependents remain in an eligible status (you are covered by TRICARE, children
are under age 21 or age 23 if a full-time student); and the Master Policy
and your class of insured persons remain in effect. So even if you or a
covered dependent develops a serious health condition in the future, the
coverage will not terminate, provided these conditions are met. Under the
Comprehensive Plan, your insured dependent’s premium will be waived for up
to one year, if you die while insured. To continue coverage beyond one year,
your surviving spouse must pay the appropriate premium.
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 Missouri while sane);
4. the following services:
- a) routine physical exams, unless required for school enrollment (but not sports physicals) by a Covered Child aged 5 through 11; and
- b) immunizations;
except that these services are covered when:
- a) rendered to a Covered Child who is less than 6 years of age; or
- b) ordered by a Uniformed Service for a Covered Spouse or Child of an Active Duty Member for such Spouse or child’s travel outside of the United States due to Member’s assignment;
5. domiciliary or custodial care;
6. eye refractions and routine eye exams except when rendered to a child up to 2 years (730 days) from his or her birth;
7. eyeglasses and contact lenses;
8. prosthesis (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:
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;
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 2 years (730 days) 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 except as specifically provided for under the Comprehensive Retiree Plan;
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; and
23. 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.”
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. INPATIENT treatment for mental, nervous or emotional disorders
in excess of 45 days if under age 19, or 30 days if age 19 or older, is
limited to 90 days (if approved by Tricare) in a calendar year. OUTPATIENT
benefits for mental, nervous or emotional disorders, drug addiction or
alcoholism are limited to a maximum of $500 in a 12 month period.
Pre-Existing Conditions Limitations
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.
Guaranteed Acceptance — Satisfaction Guaranteed
It's easy to enroll in the Tricare Extra Standard Supplement Plan. Just
download and complete the Enrollment Form — making sure to provide all
information requested — and return it with your check for the first premium
payment. That's all there is to it! You cannot be turned down for coverage,
although a pre-existing condition may initially limit the extent of your
coverage. After your completed Enrollment Form and first premium payment
have been processed, you'll receive a certificate of insurance which you
can examine for 30 days risk-free. Return it for a full refund if you are
not completely satisfied, less any claims paid.
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 any discrepancy between this website and the policy,
the terms of the policy will apply. All benefits are subject to the terms and conditions of the policy.
Policies underwriter by The Hartford Life Insurance Company detail exclusion, limitations, reduction of benefits 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 not be available to residents of all states. You will be notified by the Administrator if you are ineligible for coverage.
Administered by:
Association & Society Insurance Corporation
(Doing business in California and Texas as ASI Insurance Services; in Virginia as ASA
Administrators Inc.)
P.O. Box 2510
Rockville, MD 20847
For all inquiries, call toll-free:
1-800-638-2610
(MD, DC, VA, 301-816-0045, ext 257)
Underwritten by:
Hartford Life Insurance Company
Simsbury, CT 06089
Policy Form SRP-1269 TR (1969)
Brochure Form #SRH-3250-PQ 
