TRICARE Select Supplement
Insurance Plan





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High Option II

Young Adult

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Termination

Insured Person:Coverage under the Policy will cease on the first to occur of:
1) the date the Policy terminates, or the date the Organization ceases to be a Participating Organization of the policyholder;
2) the date the required premium is not paid, subject to the Grace Period provision;
3) the first day of the month on or next following the date you cease to be a member of the Policyholder;
4) 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;
5) the date we or the Policyholder cancel coverage for a Class of Eligible Person to which you belong;
6) the date you attain age 65;
7) the date you cease to be covered under TRICARE;
8) the date you become 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 originated before the effective date of termination.

Dependent:Dependent's coverage under the Policy will cease on the first to occur of:
1) the date the Policy terminates;
2) the date the required premium is not paid, subject to the Grace Period provision;
3) the first day of the month on or next following the date the dependent ceases to be an Eligible Spouse or an Eligible Child;
4) the first day of the month on or next following the date the dependent ceases to be eligible for the Plan under which the dependent is covered;
5) the date we or the Policyholder cancel coverage for a Class of Eligible Person to which the dependent belongs;
6) the date you cease to be covered, subject to the Covered Dependent Continuation provision (this will not apply to the Spouse or Child of an Active Duty Member or a Service Disabled Member);
7) the date the dependent becomes eligible for Medicare unless the dependent resides in an area where Medicare is not available, in which case coverage will not terminate until the dependent returns to residency in an area where Medicare is available;
8) if a child, the date the child attains age 21 or age 23 (if the child is enrolled full time at a school of higher learning); under 26 if covered by the TRICARE Young Adult Program;
9) the date a dependent ceases to be covered under TRICARE;
10) the date a dependent attains age 65.

Termination of coverage will be without prejudice to any claim which originated before the effective date of termination.




Exclusions

This 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 Colorado and Missouri, while sane);
4) routine physical exams and immunizations, except when: a) rendered to a child up to 6 years from the child’s birth; or b) ordered by a Uniform Service: i) for a Covered Spouse or Child of an Active Duty Member; ii) for such spouse or child’s travel out of the United States due to your 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 that artificial limbs and eyes and devices which must be implanted by surgery are covered);
9) cosmetic procedures, except those resulting from covered Sickness or Injury;
10) hearing aids;
11) orthopedic footwear;
12) care for the mentally incapacitated or physically handicapped if the care is required because of the mental incapacitation or physical handicap or 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 6 years from the child's 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;
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;
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.

Exclusions for the State of New York
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;
4)custodial care;
5) eye refractions and routine eye exams except when rendered to a child up to 6 years from the child’s birth;
6) eyeglasses;
7) cosmetic surgery, except that cosmetic surgery shall not include reconstructive surgery when such surgery is incidental to or follows surgery resulting from trauma, infection, or other diseases of the involved part, and reconstructive surgery because of a congenital disease or anomaly of a covered dependent child which has resulted in a functional defect;
8) hearing aids
9) dental care or treatment, except for such care or treatment due to accidental injury to sound natural teeth within 12 months of the accident and except for dental care or treatment necessary due to congenital disease or anomaly;
10) any confinement, service, or supply that is not covered under TRICARE;
11) expenses in excess of the TRICARE Cap;
12) expenses which are paid in full by TRICARE;
13) any expense or portion thereof, applied to the TRICARE Outpatient Deductible;
14) treatment for the prevention or cure of alcoholism or drug addiction except as specifically provided under TRICARE;
15) any part of a covered expense which the Covered Person is not legally obligated to pay because of payment by a TRICARE alternative program;
16) 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.












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About TRICARE | About Our Plans | How the Select Supplement Works
High Option II | Young Adult | Termination/Exclusions | Rate Schedule | How to Enroll | Return to Index