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Select the Plan Option That Meets Your Needs
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, not the 115% legal limit cap imposed by Tricare. The Comprehensive Plan has a survivor benefit, that pays the premium of 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.
The Comprehensive Plan also 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 So Easy To Enroll: Download the Enrollment Form from this website
- Print your name and address clearly on the Enrollment Form.
- Sign and date the Enrollment Form.
- Check the appropriate boxes to indicate the coverage you have chosen.
- Calculate your premium from the appropriate schedule. (Complete Checkomatic Form if you wish to pay premiums monthly)
- Make your check payable to “AMRA Group Health Program” and
mail it with your Enrollment Form and AMRA membership application to:
AMRA Insurance Administrator
P.O. Box 2107
Rockville, MD 20847
Eligibility
You are eligible to enroll provided you are an eligible TRICARE/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 premiums will be waived for up to four full years unless your spouse remarries, reaches 65, or dependents no longer remain in an eligible status. After four 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 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.
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, their coverage will not terminate, provided these conditions are met. Under the Comprehensive Plan, your insured dependent’s premium will be waived for up to four years, if you die while insured. To continue coverage beyond four years, your surviving spouse must pay the appropriate premium.
Exclusions
Treatment or confinement not ordered by a physician or necessary for medical care; intentionally self-inflicted injury; suicide or attempted suicide, whether sane or insane; sickness or injury resulting from acts of war, whether declared or undeclared; routine physical exams, eye exams, eye refractions and immunizations, except for well baby care covered by Tricare; custodial care, hearing aids, orthopedic footwear, eyeglasses or contact lenses; cosmetic procedures, except those resulting from sickness or injury occurring while a covered person; drugs (other than insulin) which do not require a prescription; any confinement, service or supply not covered under Tricare, or for expenses paid in full by Tricare; expenses in excess of the Tricare Cap; the Tricare Standard/Extra fiscal year outpatient deductible, except as specifically provided under the comprehensive plan; care of the mentally retarded or physically handicapped which is required due to the mental retardation or physical handicap; any part of a covered expense which the covered Person is not legally obligated to pay because of payment by a Tricare alternative program.
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 GuaranteedIt'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. |
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 the contents of this website and the contract, the terms of the contract will apply. Complete details are found in the certificate of insurance issued to each insured individual. Coverage is not available in MN, ND, NH, NV, OR, UT, & WA State.
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 2107
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
Hartford, Connecticut
Policy Form SRP-1269 A(HL)(1969)
Brochure Form #SRH-3250-PQ
.
The Hartford is Hartford Financial Services Group, Inc. and its subsidiaries, including the issuing company of Hartford Life Insurance Company.
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