The money for cost-shares, deductibles and excess charges will all come out of your pocket unless you

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1 Office of the Administrator P.O. Box Des Moines, IA Here's the information you requested! The MOAA MEDIPLUS TRICARE Retired Reserve Supplement Insurance Plan teamed with TRICARE Retired Reserve helps provide retired reservists and their families enrolled in the TRICARE Retired Reserve Program with stable, affordable and valuable health insurance protection. Dear MOAA Member, Thank you for your interest in MOAA s MEDIPLUS TRICARE Retired Reserve Supplement Insurance. I m pleased to send the information you requested. As you know, the FY 2010 National Defense Authorization Act (NDAA) allows all National Guard or Reserve retirees to purchase the TRICARE Retired Reserve coverage. While this coverage provides valuable and affordable health care coverage, it was not designed to cover everything. The money for cost-shares, deductibles and excess charges will all come out of your pocket unless you have a TRICARE Retired Reserve Supplement. The MEDIPLUS TRICARE Retired Reserve Supplement Plan can help you by offering you these advantages: Guaranteed acceptance*: National Guard and Reserve retirees under age 60 who are enrolled in the TRICARE Retired Reserve Program are eligible to enroll in MEDIPLUS. You, your spouse and dependent children cannot be turned down. Simply complete and return the enclosed form and you re in! Valuable Coverage: MEDIPLUS works with TRICARE Retired Reserve to help pay the covered medical bills these plans leave behind after you meet any applicable TRICARE and MEDIPLUS deductibles. So cost-shares for doctor visits and trips to the Hospital are paid by MEDIPLUS. Pays for your prescription cost-shares: Traditional co-payments for medications can add up quickly, especially when you have a family. But after TRICARE and MEDIPLUS cover their share of the bill for prescription drugs, you don t pay a cent. (Over, please) TRR-LET-0315 ILI648L-040TRR 1 Stock:

2 Helps pick up the tab for excess charges: If your TRICARE-authorized doctor charges you more than the TRICARE-allowed amount, MEDIPLUS will pay the difference up to 15% above the TRICARE-allowed amount. Gives you choice of doctors and specialists: With MEDIPLUS, you re free to choose the TRICARE-authorized doctor you want. You can decide which specialist you want to see without a referral. Covers you for new health conditions right away: From the very start of your coverage, you ll be protected for any new illnesses or injuries. Any current health conditions will not be covered until after six months. (If you switch to MEDIPLUS from employer-sponsored protection because you move, change jobs or retire, or if you apply within 30 days of initial eligibility for TRICARE Retired Reserve, this six-month waiting period can be waived.) Affordable group rates: Thanks to the group buying power of more than 380,000 members, you qualify for economical group rates. Review the enclosed rate information for more details based on the MEDIPLUS option you choose. The MEDIPLUS Benefits Summary enclosed provides more details about these and other features of the plan. Then to enroll, simply complete and return the enclosed Enrollment Form. Send no money now. Once your form is processed, we will then send you a bill. We look forward to your participation in this valuable MOAA-endorsed program. Sincerely, Timothy R. Weber, Partner Mercer Health & Benefits Administration LLC MOAA Insurance Plans Administrator License # Katherine E. Partain Vice President, Membership & Marketing Member Products & Services Military Officers Association of America P.S. MEDIPLUS is a guaranteed acceptance* benefit as a member of MOAA, and it s easy to get today. Just complete and return the enclosed Enrollment Form. Then you can enjoy the high-quality supplemental insurance protection, affordable group rates and other plan conveniences MEDIPLUS offers you and your family. Act today! *This policy is guaranteed acceptance, but it does contain a Pre-Existing Conditions Limitation. Please refer to the enclosed brochure for more information on exclusions and limitations, such as Pre-Existing Conditions. Please read the enclosed materials for more information, including costs, exclusions, limitations and terms of coverage. Form SRP-1269 ASN (1134) Copyright 2017 Mercer LLC. All rights reserved. Questions? Call toll-free :30 a.m. to 5:00 p.m. Central Time, Monday - Friday or visit us online at ILI648L-040TRR 2

3 MEDIPLUS TRICARE RETIRED RESERVE SUPPLEMENT INSURANCE ENROLLMENT FORM Complete all information in ink. 1. Complete the following information: AGP RR-Q Endorsed by: NOTE: Name must be identical to how it appears on your military ID card. *Widow(er)s do not need to complete these items. Underwritten by: Hartford Life Insurance Company in ME, MD, MN and MT, and by Hartford Life and Accident Insurance Company in all other states. Home office of both companies is Simsbury, CT Member Name: Address: The Hartford is The Hartford Financial Services Group, Inc., and its subsidiaries, including issuing company Hartford Life and Accident Insurance Company and Hartford Life Insurance Company. City: State: ZIP: Member Social Security Number: Date of Birth: Address: Sex: Rank/Service*: Daytime Phone: Date TRICARE Reserve Select coverage begins: MOAA Member Number: mo day Male mo day yr Female yr Membership Type: (Check one) MOAA Member MOAA Auxiliary Member Certificate Number: (If you are already enrolled in MEDIPLUS and this form is for additional coverage or a change in coverage, insert your current certificate number here.) 2. Please select the MEDIPLUS TRICARE Retired Reserve Supplement you want. (Note: You're classified as a "nonsmoker" if you haven't smoked a cigarette, cigars, or used a pipe or chewing tobacco, nicotine product or snuff in the past 12 months.) IN- and OUTPATIENT PLANS RETIRED WITH $400 PER PERSON DEDUCTIBLE RETIRED WITH $250 PER PERSON DEDUCTIBLE Member Nonsmoker (CL61) Smoker (CS61) Nonsmoker (CL51) Smoker (CS21) Spouse Nonsmoker (CL65) Smoker (CS65) Nonsmoker (CL56) Smoker (CS26) Child(ren) Under age 21 (CL67) (23 if a full-time student) Under age 21 (CL57) (23 if a fill-time student) (Over, please) TRR-ENR-0315 ILI648E-040TRR 1 Stock:

4 3. Please complete if your family is enrolling. (NOTE: Name(s) must be identical to how they appear on military ID card.) Spouse Name: Sex: M F Date of Birth: Child Name: Sex: M F Date of Birth: Child Name: Sex: M F Date of Birth: Child Name: Sex: M F Date of Birth: mo mo mo mo day day day day yr yr yr yr Children must be under age 21 (23 if a full-time student or 26 if enrolled in TRICARE Young Adult). Please include proof of full-time status or proof of enrollment in TRICARE Young Adult with your application. If you would like to enroll more than 3 children, please attach a separate sheet that includes the information requested. 4. Please complete these questions. Member (Note: The MOAA member should answer questions even if only requesting child coverage.) YES NO Spouse (if applying) YES NO A. Have you or anyone enrolling for coverage smoked cigarettes, cigars, or used a pipe or chewing tobacco, nicotine product or snuff within the past 12 months?... B. Are you enrolling within 30 days of the date your employer health insurance ends because you are no longer an eligible participant in that program?... C. Are you enrolling within 30 days of initial eligibility for TRICARE Retired Reserve benefits? Please read, sign and date: I hereby enroll myself and/or my dependents with Hartford Life and Accident Insurance Company for coverage under the Military Officers Association of America Group Health Insurance Program (MEDIPLUS). I certify that I am a member of MOAA and understand that I must retain membership to be eligible for MEDIPLUS. I understand that this program will not cover pre-existing conditions (conditions [including pregnancy] for which medical advice or treatment was rendered or recommended by a physician for those being enrolled within six months of this new coverage) unless six months have passed from the effective date of this new coverage. This pre-existing condition limitation will not apply if waived in accordance with policy provisions. If I increase my coverage, the amount of the increase will be subject to the pre-existing condition limitation. I understand that eligibility to receive benefits under the TRICARE Retired Reserve Supplement is dependent on my (or my deceased spouse s) purchase of TRICARE Retired Reserve. I have read the MEDIPLUS Acknowledgement and the Important Definitions section of the brochure and agree to accept these terms. I understand that once my enrollment form has been processed, a MEDIPLUS certificate will be mailed to me. My MEDIPLUS protection will begin on the first day of the month after the Plan Administrator receives this enrollment form and my first premium payment. California residents only: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage. Florida residents only: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony in the third degree. Maryland residents only: 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. Member's Signature X Date X Don't send money now! You'll be billed later. Mail your completed Enrollment Form to: MOAA Insurance Plans P.O. Box Des Moines, IA Questions? Call Toll-Free (Hearing-impaired or voice-impaired members may call the Relay Line at ) Or, moaa.service@mercer.com Policy Form #SRP-1269 ASN (1134) Copyright 2017 Mercer LLC. All rights reserved. ILI648E-040TRR 2

5 AUTOMATIC CHECK WITHDRAWAL REQUEST: By selecting Automatic Check Withdrawal, your premium will automatically be withdrawn from your checking account. Please provide the information requested below. Routing #: Account #: I request that you pay and charge my account debits drawn from my account by the Plan Administrator to its order. This authorization will stay in effect until I revoke it in writing. Until you receive such notice, I agree that you shall be fully protected in honoring any such debits. I also agree that you may, at any time, end this agreement by giving 30 days advanced written notice to me and to the Plan Administrator. You are to treat such debit as if it were signed by me. If you dishonor such debit with or without cause, I will not hold you liable even if it results in loss of my insurance. Signature of Premium Payer Date

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7 MEDIPLUS TRICARE Retired Reserve Supplement Insurance Plan Summary of Benefits 1. Guaranteed Acceptance for You and Your Family 4. Choose Your Own Doctor Retired National Guard and Reserve MOAA members under age 60 and covered by TRICARE Retired Reserve, are guaranteed acceptance in MEDIPLUS. You and your family cannot be turned down; however, insurance benefits payable are subject to your policy s Pre-Existing Conditions Limitation. You can also enroll your spouse or children without enrolling yourself. Your spouse is eligible as long as he or she is under age 60 and not legally separated or divorced from you. Your unmarried children are eligible for coverage if they are under 21 (23 if enrolled full-time in higher learning or 26 if enrolled in TRICARE Young Adult). With MEDIPLUS, you re free to choose your own TRICARE-authorized doctor or specialist (with no referrals)...whenever you like. 2. MEDIPLUS Teams with TRICARE Retired Reserve Switching from an employer health plan or after your initial eligibility for TRICARE Retired Reserve is easy. 5. Select The Plan that Works Best for You MEDIPLUS TRICARE Retired Reserve Supplement offers In- and OutPatient Coverage. Choose between two deductible options to help fit into your budget. $250 per person/$500 per family $400 per person/$800 per family 6. Switching to MEDIPLUS from Other Coverage is Easy MEDIPLUS and TRICARE work together to help pay your covered medical bills, like Hospital stays, doctor visits and prescription drugs. Leaving your employer plan: You qualify for MEDIPLUS with no waiting period for current health conditions if you sign up within 30 days after your employer-sponsored plan ends because you are no longer an eligible participant (for example, if you change jobs, move, or retire). If you voluntarily end your employer plan while you are still an eligible participant, you ll wait six months from your effective date of coverage before current health conditions are covered. 3. MEDIPLUS Covers Excess Charges If your doctor charges you more than what TRICARE allows, you re left to pay the rest of the bill. Not with MEDIPLUS. That s because MEDIPLUS pays up to 15% above the TRICARE-allowed amount after the TRICARE and Plan deductibles are met. This is especially valuable because excess charges can t be applied to TRICARE s catastrophic cap. TRR-BRO-0315 ILI648P-040TRR 1 Stock:

8 Just eligible for TRICARE Retired Reserve coverage? You ll have NO waiting period when you enroll within 30 days of the date of your initial eligibility for TRICARE Retired Reserve benefits. 10. Coverage Starts Right Away Your MOAA MEDIPLUS coverage begins the first day of the month after the administrator receives your completed Enrollment Form and your first premium payment. MEDIPLUS covers all new health conditions right away. For current health conditions, the waiting period is six months. Changing your military status? If your military status or your eligibility for TRICARE changes, your MEDIPLUS coverage can change with you. If you come off TRICARE Retired Reserve, you can continue your MEDIPLUS Supplement with TRICARE Standard. And if you switch to TRICARE Prime for retirees, you can also switch to a MEDIPLUS TRICARE Prime Supplement. You just need to notify the MEDIPLUS Insurance Plan Administrator of your change in status. 11. Affordable Group Rates MOAA s large numbers more than 380,000 members equals leverage when negotiating benefits and rates for you. Because of this mass purchasing power, you ll generally pay less for MEDIPLUS than other plans. See group rates on last page. 7. DirectClaim Electronic Filing of MEDIPLUS TRICARE Supplement Claims 12. Backed by MOAA MOAA endorses only one TRICARE supplement on the market MEDIPLUS. You can trust MOAA to only recommend a plan that meets their strict guidelines. Trust more than 30,000 (about 1 out of every 3 eligible MOAA members under age 65) of your fellow officers and their families who already believe in MEDIPLUS. DirectClaim involves less paperwork saving you time and processes your claims quicker. With DirectClaim, you will not have to complete MEDIPLUS claim paperwork after you access most of your eligible TRICARE benefits. Some claims cannot be processed electronically, such as prescription claims and most skilled nursing or skilled nursing facility, nursing home claims and claims filed from overseas % Guaranteed Satisfaction Your satisfaction is guaranteed with MEDIPLUS. Take up to 30 days to examine the coverage. Pay for it only after you determine it s the right protection for you. If you re not completely satisfied with MEDIPLUS after the 30-day free look, return your certificate for cancellation of your enrollment. There will be no questions asked, and you haven t spent a cent. Note: It s important that the MEDIPLUS applicant s name appears on the enclosed enrollment form the same as it is on their military ID card to ensure proper claims processing with DirectClaim. 8. MEDIPLUS TRICARE Retired Reserve Supplement Benefits Can Continue Premium-Free Questions About This Coverage? MEDIPLUS acts as a safety net for your family if something happens to you. As a retired member, if you die, your eligible spouse s MEDIPLUS coverage continues premium-free until he or she remarries, reaches age 65 or becomes Medicare- eligible. Call: Visit: moaa.service@mercer.com Our hearing-impaired or voice-impaired members may call the Relay Line at Your eligible children can also continue their MEDIPLUS protection premium-free for up to 10 years, or until they marry, or reach age 21 (23 if a full-time student or 26 if enrolled in TRICARE Young Adult). Your family automatically qualifies for this benefit as long as you, your spouse and children are continuously covered by MEDIPLUS for at least six months before you die. Administered by: Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box Des Moines, IA Keep MEDIPLUS Wherever You Go AR Insurance License # CA Insurance License #0G39709 In CA d/b/a Mercer Health & Benefits Insurance Services LLC MEDIPLUS is yours to keep even if you change jobs or move. The protection can stay with you; your MEDIPLUS protection will not be canceled due to claims or a change in your health, and you won t be singled out for a rate increase. As long as you pay your premiums on time, keep your MOAA membership, and the MEDIPLUS Master Policy remains in force, you can continue your MEDIPLUS coverage. Your dependent s coverage will remain in effect as long as your coverage is active, premiums are paid and they meet the eligibility requirements. Sponsored by: 2 ILI648P-040TRR

9 Underwritten by: insane (in Missouri, while sane); 4.) routine physical exams and immunizations, except when: 5.) rendered to a Child who is less than 6 years of age; or a) required for school enrollment (but not sports physicals) by a Child aged 5 through 11; 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 out of the United States due to the Member s assignment; 6.) domiciliary or custodial care; 7.) eye refractions and routine eye exams except when rendered to a child up to 6 years from his or her birth; 8.) eyeglasses and contact lenses; 9.) prosthetic devices, except those covered by TRICARE; 10.) cosmetic procedures, except those resulting from Sickness or Injury while a Covered Person; 11.) hearing aids; 12.) orthopedic footwear; 13.) care for the mentally or physically incapacitated if: a) the care is required because of the mental or physical incapacitation; or b) the care is received by an Active Duty Member s child through the TRICARE Extended Care Health Option (ECHO); 14.) drugs which do not require a prescription, except insulin; 15.) dental care unless such care is covered by TRICARE, and then only to the extent that TRICARE covers such care; 16.) any confinement, service, or supply that is not covered under TRICARE; 17.) Hospital nursery charges for a well newborn, except as specifically provided under TRICARE; 18.) any routine or newborn care except Well Baby Care, as defined; 19.) expenses which are paid in full by TRICARE; 20.) 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 21.) 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 Conditions Limitation. 22.) any expense applied to the TRICARE Outpatient Deductible, TRICARE Point-of-Service Deductible, Retiree Inpatient Only Supplement Deductible or Retiree Inpatient/Outpatient Supplement Deductible. Nervous, Mental, and Emotional Disorder, Alcoholism and Drug Addiction Limitations: The coverage provided under the TRICARE Hartford Life Insurance Company in ME, MD, MN, and MT, and Hartford Life and Accident Insurance Company in all other states. Home office of both companies is Simsbury, CT The Hartford is The Hartford Financial Services Group, Inc., and its subsidiaries, including issuing companies Hartford Life and Accident Insurance Company and Hartford Life Insurance Company. This fact sheet explains the general purpose of the insurance described, but in no way changes or affects the Master Policy AGP-1134 (Policy Form #SRP-1269 ASN [1134]) 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 the Hartford Life and Accident Insurance Company and Hartford Life Insurance Company detail exclusions, 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 the insured individual and the Master Policy issued to the policyholder. This program may vary and may not be available to residents of all states. Your association shares a financial interest in this program, which benefits the entire membership. Copyright 2017 Mercer LLC. All rights reserved. IMPORTANT DEFINITIONS Qualified Hospital: A Hospital must be engaged primarily in medical care and treatment of sick and injured persons on an inpatient basis, have full surgical facilities, be under the supervision of legally qualified physicians, and provide 24-hour nursing services by R.N.s to qualify. A sanitarium operated by or certified by the First Church of Christ Scientist, Boston, Massachusetts, also qualifies. A convalescent home; Skilled Nursing Facility; a place for rest, custodial care or for the aged; or a place primarily caring for mental illness, drug addiction, or alcoholism does not qualify. In certain situations, an institution for the treatment of nervous, mental or emotional disorders is considered a Hospital under the MEDIPLUS TRICARE supplements. Confined or Confinement means being an inpatient in a Hospital or Skilled Nursing Facility due to Sickness or Injury. Pre-Existing Conditions Limitation: If you or your covered dependents received medical treatment or advice for a health condition (including pregnancy) during the six months before the date your protection starts, that health condition won t be covered until the person has been enrolled in the plan for six months. Please consider this limitation before canceling any other health insurance you may have. General Exclusions and Limitations: These TRICARE Supplements do 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 supplement does not cover inpatient treatment for mental, nervous, or emotional disorders in excess of 45 days if under age 19, or in excess of 30 days if age 19 or older (or 90 days if approved by TRICARE Standard) in any one calendar year. Outpatient benefits for such disorders are limited to $500 during any period of 12 consecutive months. In addition, for mental illness we will pay up to 150 days of inpatient care in a TRICARE-authorized Residential Treatment Center for a covered dependent child up to age 21. Important Information Regarding Veterans Administration (VA) Hospitals: TRICARE supplement insurance policies pay benefits only after TRICARE has first reviewed and approved the expense. A review by TRICARE results in a TRICARE Explanation of Benefits ( EOB ). Many VA Hospitals currently do not submit their claims through TRICARE. Only claims TRICARE processes, resulting in an EOB, are subject to benefits under Hartford Life and Accident Insurance Company s TRICARE supplement insurance policies. If you use VA facilities for your care, please be aware of this TRICARE supplement policy requirement. VA hospitals also can charge the veteran a Category C co-payment based on a means test per Public Law 99 Section 272. This law specifically applies only to the veteran and not the insurance company. ILI648P-040TRR 3

10 MEDIPLUS Affordable Group Rates MOAA's large numbers more than 380,000 members equals leverage when negotiating benefits and rates for you. Because of this mass purchasing power, you'll generally pay less for MEDIPLUS than other plans. TRICARE Retired Reserve Supplements Monthly Rates*: In- and Outpatient Plans Retiree $400 Per Person Deductible $250 Per Person Deductible Nonsmoker Smoker Nonsmoker Smoker Under 45 $14.86 $15.78 $26.03 $27.66 Age Member/ $16.71 $18.56 $29.29 $32.54 Auxiliary $23.22 $25.07 $40.68 $43.93 Member $31.58 $33.42 $55.32 $ $40.04 $44.05 $71.00 $78.10 Under 45 $20.44 $23.22 $35.80 $ $25.07 $27.85 $43.93 $ $30.64 $34.35 $53.69 $ $34.35 $39.00 $60.20 $ $42.04 $47.06 $74.55 $83.42 Spouse Each Child $13.93 $24.42 *For your convenience, you will be billed quarterly. Premiums are based on each person s age when coverage becomes effective and increase upon entry into each new 5-year age bracket. Rates and/or benefits may be changed on a class-wide basis. Upon reaching age 60, your MEDIPLUS coverage will continue under the MEDIPLUS TRICARE Standard Supplement Insurance Plan. The age rates listed are for the MEDIPLUS TRICARE Standard Supplement. If you are age 65 or older and ineligible for Medicare, you can continue MEDIPLUS as long as you remain TRICARE eligible. Please contact the Plan Administrator for age 65+ rates. If you choose a supplement with a plan deductible, your 12-month deductible period will begin with the effective date of your coverage. (This may not coincide with the TRICARE fiscal year deductible period.) If you need to change your TRICARE supplement because you have changed your primary coverage from TRICARE Retired Reserve to TRICARE Prime or Standard), please contact the administrator at Nonsmoker means a Covered Person who has not smoked cigarettes, cigars, or used a pipe or chewing tobacco, nicotine product or snuff during the 12 months prior to the date he or she applied for coverage. ILI648P-040TRR 4

11 How the MEDIPLUS TRICARE Retired Reserve Supplement Works With TRICARE Retired Reserve Type Of Care: TRICARE Retired Reserve Pays: With TRICARE Retired Reserve Benefits Only You Must Pay: The MEDIPLUS TRICARE Retired Reserve Supplement Pays: FOR INPATIENT CARE Civilian Hospital (Room, board, supplies and staff services billed by the hospital) The TRICARE Diagnosis Related Group (DRG) amount minus your cost-share. The DRG daily cost-share amount or 25% of the bill, whichever is less.** The DRG daily cost-share amount or 25% of the bill, whichever is less, after you meet the selected annual plan deductible PLUS covered excess charges up to 15% above the amount TRICARE allows. FOR INPATIENT CARE Civilian Hospital (Doctors and other inpatient services not billed by the hospital) 75% of the amount TRICARE allows for doctor and professional services. 25% of the TRICARE allowed amount for medical services such as doctor charges or lab work plus the difference between the actual charges and the allowed amount.** The remaining 25%* after you meet the selected annual plan deductible PLUS covered excess charges up to 15% above the amount TRICARE allows. FOR INPATIENT CARE Government Hospital Nothing. Current daily subsistence charges. Current daily subsistence charges. FOR OUTPATIENT CARE (Doctor visits, clinics, outpatient surgeries) 75% of the amount TRICARE allows after the annual TRICARE deductible. The remaining 25% PLUS the annual TRICARE outpatient deductible PLUS all charges over the allowed amount.*** The remaining 25%* after the TRICARE outpatient deductible and the selected plan deductible*** PLUS covered excess charges up to 15% above the amount TRICARE allows. Putpatient Prescription Drugs (From civilian TRICARE retail network pharmacy) The TRICARE-allowed amount minus your cost-share. The co-pay amount due for a 30-day supply based on the type of prescription. The prescription co-pay amount due for a 30-day supply after you meet the selected annual plan deductible. (From TRICARE Mail Order Pharmacy) The TRICARE-allowed amount minus your cost-share. The co-pay amount due for a 90-day supply based on the type of prescription. The prescription co-pay amount due for a 90-day supply after you meet the selected annual plan deductible. (From a non-network pharmacy) The TRICARE-allowed amount minus your cost-share after the annual TRICARE deductible. The annual TRICARE outpatient deductible, PLUS the co-pay amount due for a 30-day supply based on the type of prescription. The prescription co-pay amount due for a 30-day supply after you meet the TRICARE outpatient deductible and the selected annual plan deductible. If TRICARE does not pay according to the DRG system, the TRICARE reimbursement will be 75% of the allowed amount. *If you have other coverage that will pay before your MEDIPLUS and TRICARE benefits begin, TRICARE payment may be less than 75% of the allowed amount. MEDIPLUS will limit its payment to an amount which when added to the amounts paid by the Employer Health Program and TRICARE, will not exceed 100% of TRICARE covered expenses. **TRICARE limits retirees to $3,000 per year for deductibles and copayments ($1,000 for Active Duty family members). Please remember, however, non-network providers may charge up to 15% above the TRICARE allowable charge. You are responsible for these extra charges. ***Expenses used to satisfy the TRICARE outpatient deductible may not be applied toward the annual plan deductibles in the Inpatient and Outpatient Plans with Deductible. Please Note: Your MEDIPLUS deductible period will start with your effective date. (This may be different than TRICARE's fiscal year deductible period, which begins on October 1st of each year). ILI648P-040TRR 5

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