You ll find everything you need to make a decision for you and your family enclosed.

Transcription

1 Information Request For AFA Member: Here s the TRICARE Prime Supplement Insurance Plan information you requested. Dear AFA Member, Thank you for requesting more information about the TRICARE Supplement Insurance Plans designed for eligible members of the Air Force Association, underwritten by Transamerica Premier Life Insurance Company, Cedar Rapids, IA. You ll find everything you need to make a decision for you and your family enclosed. As you may already know, TRICARE Prime is Department of Defense managed care health care program for the military community. The TRICARE Prime Supplement Insurance Plans available to you herein are designed to help pay your cost-shares and copayments under TRICARE (In-Network and Out-of-Network expenses). This may save you and your family hundreds of dollars a year. Plus, you ll appreciate these features: Available regardless of rank or service E- through 0-0. Gives you a choice between two options to fit your budget. Protects your eligible spouse and dependent children. Competitive group rates. Thanks to your AFA membership, you qualify for competitive group rates. Please review the enclosed Benefits Summary for your rates and other important details about this plan. Then to enroll, complete and return the enclosed Enrollment Form. Send no money now. Coverage is available for your TRICARE eligible spouse under age 65, and dependent, unmarried children under age 2 (23 if a full-time college student). Once your form is received, we will send you a Certificate of Insurance. You ll have 30 days to look over the plan benefits. If you decide to continue with this coverage, pay the bill accompanying your Certificate. If you decide it s not what you had in mind, simply let us know. You re under no obligation. (Over, please) AFATPL

2 Thank you again for considering this valuable TRICARE Prime Supplement Plan. We look forward to your participation. Sincerely, Sincerely, Janeé Williams Manager, Member Relations Air Force Association Timothy R. Weber, Partner Mercer Health & Benefits Administration LLC AFA Insurance Plans Administrator License # P.S. Take advantage of your AFA membership and enroll in this valuable TRICARE Prime Supplement Plan today. It s easy to do Just complete and return the enclosed Enrollment Form. Send no money now! Underwritten by: Transamerica Premier Life Insurance Company, Cedar Rapids, IA (TPLIC) Policy# MZ H0000A Copyright 207 Mercer LLC. All rights reserved. AFATPL 2 AT#676600

3 205TC-Q AFAVBA Group TRICARE Prime Supplement Plan Enrollment Form Please Leave Blank Ref. No. Check the appropriate box: n New Enrollment Form n Add Dependent(s) n Change Coverage Transamerica Premier Life Insurance Company Administrative Office: Cedar Rapids, Iowa POLICY HOLDER: AIR FORCE ASSOCIATION VETERAN BENEFITS ASSOCIATION ORGANIZATION: AIR FORCE ASSOCIATION VETERAN BENEFITS ASSOCIATION ENROLLMENT FORM Name n Mr. n Mrs. n Ms. First M.I. Last Address City State Zip Rank/Grade Telephone No. Home Office Name of each dependent for whom coverage is desired: Spouse Name: nnn Child Name: nnn Child Name: nnn Child Name: Child Name: nnn nnn Select the coverage you want: Check the brochure for the appropriate premium schedule. Retired Member Spouse of Retired Member Each Child of Retired Member n Plan A (PA) n Plan A (PA5) n Plan A (PA7) n Plan B (PB2) n Plan B (PB25) n Plan B (PB27) I hereby enroll myself and/or my dependents with the Transamerica Premier Life Insurance Company for coverage under the AFAVBA supplemental insurance plan. I understand that I must be a member of AFAVBA to be eligible for coverage and that my coverage will become effective on the first day of the month following receipt of this enrollment form and premium. I understand that any injury or sickness, whether diagnosed or undiagnosed, for which any person proposed for coverage has received medical treatment or care within the 6 months immediately preceding their effective date will not be covered until that person has not received medical treatment or care for that condition during a period of 6 consecutive months ending on or after his or her effective date. After 6 months from that person's effective date, he or she will become covered regardless of any preexisting conditions he or she may have. I further understand that new conditions will be covered immediately. AR, CO, KY, LA, NM, OH, OK, and TN Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of a claim or an application containing any false, incomplete or misleading information is guilty of a crime and may be subject to fines or confinement in prison. DC and RI Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FL Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of a claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. NJ Residents: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. MD Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. PA Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. Date: Member s Signature (X): Date: Spouse s Signature (X): MLTRC000GE (If Applying) AFAVBA 83-4/0 (See reverse side for partial list of services and cost share amounts) AFATPA MZ H0000A AT#676600

4 The following chart is an example of what the TRICARE Prime Supplement pays for some of the most common types of services. Refer to your TRICARE Prime Handbook for a more complete description of terms and conditions under TRICARE. Care Required TRICARE Prime Pays Tricare Prime Supplement Pays All except the following: Per Visit/Service: Civilian Outpatient Care Per Visit: $2 Office $2 $30 Emergency Room $30 Outpatient Mental Health $25 Individual $25 Individual $7 Group $7 Group Civilian Inpatient Admission $/day $/day ($25 minimum per admission) ($25 minimum per admission Inpatient Mental Health $40/day $40 Ambulance Service $20 $20 Outpatient Ambulatory Surgery $25 $25 Prescription Drugs $0/$5 Generic $0/$5 Generic $3/$7 Brand Name $3/$7 Brand Name $43/$44 Non-Formulary $43/$44 Non-Formulary SEND NO MONEY NOW After completion, sign and date the form where indicated. Keep a copy for your records and return the original to: Mercer Consumer, P.O. Box 4464, Des Moines, IA Questions Call Toll-Free (7:00a.m.-5:00p.m. Central). Or, afa.service@mercer.com AFAVBA 83-9/0 AFATPA 2 AT#676600

5 TRICARE Prime Supplement Insurance Plan Benefits Summary Guaranteed Issue You are guaranteed issue provided you are an eligible retired Air Force Association member, under age 65, and currently enrolled in TRICARE Prime. Coverage is also available for your TRICARE eligible spouse under age 65, and dependent, unmarried children under age 2 (23 if a full-time college student). Coverage is extended to adult dependent children who are under age 26 and enrolled in the TRICARE Young Adult (TYA) program. In addition, coverage is available to eligible surviving spouses who are enrolled in TRICARE Prime. Helps Pay Expenses TRICARE Prime Doesn t TRICARE provides excellent health care coverage. However, it was never designed to cover all expenses. This Supplement Insurance Plan works with TRICARE Prime may help pay your cost-shares and copayments once you meet any TRICARE and plan deductibles. Please see the charts below for how the TRICARE Prime Supplement plans pay for services. In-Network Charges The Plan Pays Plan A Your eligible TRICARE Prime copayments and cost shares up to the TRICARE Prime catastrophic limits. Plan B Your eligible TRICARE Prime copayments and cost shares up to the TRICARE Prime catastrophic limits. What the TRICARE Prime Supplement Pays Out-of-Network Charges (Point of Service Option) The Plan Pays Nothing 50% of the TRICARE allowed amount 2 (your cost share) for In-Patient and Out-Patient charges after you pay the Point of Service deductible. You Pay The Point of Service deductible 3 your 50% cost share for Out-of-Network charges and charges in excess of the TRICARE-allowed amount. The Point of Service deductible 3 and charges in excess of the TRICARE allowed amount. In-Network-$3,000 per enrollment year for retirees and dependent. In-Network Care must be provided or referred by a Primary Care Manager; or referred by a Health Care Finder; or is for an emergency. 2 Subject to a maximum payable under this benefit of $7,500 per family per fiscal year. 3 These plans do not pay the TRICARE Prime annual enrollment fee. The Prime Supplement Plan A and B are not available in NC and ND. Plan B is not available in FL, VT and IA. The following chart is an example of what the TRICARE Prime Supplement pays for some of the most common types of services. Refer to your TRICARE Prime Handbook for a more complete description of terms and conditions under TRICARE. Care Required TRICARE Prime Pays TRICARE Prime Supplement Pays All except the following: Per Visit/Service: Civilian Outpatient Care Per Visit: $2 Office $2 $30 Emergency Room $30 Outpatient Mental Health $25 Individual $25 Individual $7 Group $7 Group Civilian Inpatient Admission $/day $/day ($25 minimum per admission) ($25 minimum per admission Inpatient Mental Health $40/day $40 Ambulance Service $20 $20 Outpatient Ambulatory Surgery $25 $25 Home Delivery/Network Pharmacy $0/$5 Generic $0/$5 Generic $3/$7 Brand Name $3/$7 Brand Name $43/$44 Non-Formulary $43/$44 Non-Formulary *Please note: A pre-existing condition may initially limit the extent of your coverage. AFATPB (Over, please)

6 Competitive Group Rates As a retiree, spouse, or surviving spouse, you benefit from your Air Force Association membership. The result: these competitive group rates to fit your budget. (Note: MONTHLY rates shown below.) Age Plan A Plan B (Premiums shown are per person) Under 40 $3.67 $ $4.33 $ $7.00 $ $2.00 $ $25.67 $ $29.00 $36.33 Each Child* $2.33 $5.00 Change of Policy Premiums. The Plan Underwriter has the right on each Premium Due Date to change the rate at which premiums will be calculated. This includes the right to change premium rates for a benefit that applies to all individuals of the same class, age, plan and effective date. Rates may be changed based on claims experience of the policy. We will give the policyholder or organization notice of any change at least 45 days before the premium due date on which it is to become effective. Premiums increase based on your effective date of coverage and as you move from one age bracket to another. The insurance company reserves the right to change premiums on a group wide basis. *Newborn children not named in your enrollment form are automatically covered from birth for injury or sickness, including treatment of congenital defects and birth abnormalities, for 3 days. You must notify the Plan Administrator in writing and pay the additional premium due within 3 days of birth for coverage to continue beyond this period. Insured children who are incapable of self-sustaining employment because of mental retardation or physical disability- and who are unmarried and chiefly dependent on the insured member for support and maintenance may continue coverage past policy age limits, with requested proof. Otherwise, each dependent child s coverage terminates on the premium due date following the date he or she is no longer a dependent. Rates are based on the attained age of the insured person and increase as you enter each new category. Rates and/or benefits may be changed on a class basis. It s easy to enroll Just complete the enclosed Enrollment Form making sure to provide all information requested and return it. Send no money now. After your completed Enrollment Form is received, you ll be sent a certificate of insurance, which you can examine for 30 days risk-free. Important Information About this 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. Deferred Effective Date: If on the date 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 (Dependents): 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. 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 Prime. Inpatient treatment for mental, nervous or emotional disorders in excess of 45 days if under age 9, or 30 days, if 9 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 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. AFATPB 2

7 Exclusions The Policy does not cover:. 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: a) rendered to a child up to 6 years from his or her birth; or b) ordered by a Uniformed Service: () 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 the child s birth; 7. eyeglasses and contact lenses; 8. prosthetic devices, except those covered by TRICARE; 9. cosmetic procedures, except those resulting from Sickness or Injury while a Covered Person; 0. hearing aids;. orthopedic footwear; 2. 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; 3. drugs which do not require a prescription, except insulin; 4. dental care unless such care is covered by TRICARE, and then only to the extent that TRICARE covers such care; 5. any confinement, service, or supply that is not covered under TRICARE; 6. Hospital nursery charges for a well newborn, except as specifically provided under TRICARE; 7. any routine newborn care except Well Baby Care, as defined, for a child up to 6 years from his or her birth; 8. expenses in excess of the TRICARE Cap; 9. expenses which are paid in full by TRICARE; 20. any expense or portion thereof applied to the TRICARE Outpatient Deductible; 2. treatment for the prevention or cure of alcoholism or drug addiction except as specifically provided under TRICARE and the Policy; 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 Termination Your coverage under the Policy will cease on the first to occur of: a) the date the Policy terminates; b) the date the required premium is not paid, subject to the Grace Period provision; c) the first day of the month on or next following the date you cease to be a member of the policyholder; d) 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; e) the date we or the group cancel coverage for a Class of Eligible Person to which you belong; f) the date you cease to be covered under TRICARE; g) the date you becomes 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 occurred before the effective date of termination. 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). This brochure 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 brochure 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 may not be available in all states; you will be advised. This is a supplemental health insurance plan that requires you to have major medical coverage, Medicare, or other health coverage that meets minimum essential coverage as defined by the Affordable Care Act. Administered by: Underwritten by: Transamerica Premier Life Insurance Company, Cedar Rapids, IA (TPLIC) Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box 4464 Des Moines, IA AR Insurance License # CA Insurance License #0G39709 In CA d/b/a Mercer Health & Benefits Insurance Services LLC QUESTIONS? Call: afa.service@mercer.com AFATPB 3 AT#676600