Goes With You Anywhere
AFAVBA's TRICARE Supplement is completely portable, it goes with you when you travel or change jobs. It is the ideal choice for you if you are self-employed or if your employer does not offer insurance.

Exclusions and Limitations Apply To Your TRICARE Supplement Coverage

Who Is Eligible for Coverage?

Active Duty Family Plan
Your spouse (under age 65) and unmarried dependent children under age 21 (age 23 if a full-time student) are eligible for coverage. All family members must be covered by TRICARE.

Retiree Plans
You, your spouse (under age 65) and unmarried dependent children under age 21 (age 23 if a full-time student) are eligible for coverage. All family members must be covered by TRICARE.

When Does Coverage Start And End?

Effective Date of Coverage
Your coverage will become effective on the first day of the month following the date your enrollment form is received. If you are confined in a hospital on the date you are to become covered under the policy, your coverage will be deferred until the first day after you are discharged.

Renewability
Your coverage will remain in effect as long as you continue to pay your premiums when due, the group policy remains in force, and you remain eligible for coverage. Your coverage ends when you become eligible for Medicare, or you reach age 65 (unless you are not eligible for Medicare).

Extension of Benefits for Total Disability
If a covered person is Totally Disabled on the date his or her coverage ends, TRICARE supplement coverage will extend inpatient benefits until the date he or she is no longer Totally Disabled; or 90 days from the date his or her Inpatient Benefit ended, whichever is the first to occur. Outpatient Benefits under the Plan will continue up to 90 days from the date of termination. The continuation will only apply to expenses incurred for the injury or sickness that caused the total disability.

1 Expenses used to satisfy the TRICARE outpatient deductible are not covered and may not be applied toward your plan deductible.

2 Until the TRICARE cap has been met.

3 Expenses used to satisfy the TRICARE outpatient deductible are not covered.

4 This supplement does not cover the TRICARE Point-of-Service Cost Share Amount

5 After you meet the annual fiscal year $250 plan deductible

How Much Does It Cost?

Active Duty Family Plan
Monthly Premium

Each Child $18.00

Each Child $10.00

Rates are based on attained age on the premium due date for each covered person.

What’s Not Covered?

Pre-Existing Conditions Limitation
Any injury or sickness, whether diagnosed or undiagnosed for which any person proposed for coverage has received medical treatment or care within the 12 months (6 months in California, Indiana and Montana) immediately preceding their effective date will not be covered: (a) until that person (except in California, Indiana and Montana) has not received medical treatment or care for that condition during a period of 12 consecutive months ending on or after his or her effective date; or (b) until the end of a 6 month period from the person’s effective date in California or the end of a 12 month period from the person’s effective date in Indiana and Montana. After 2 years (1 year in Indiana Montana, North Carolina and South Carolina; 6 months in California) from that person’s effective date, he or she will become covered regardless of any pre-existing conditions he or she may have. New conditions will be covered immediately.

Nervous, Mental, Emotional Disorder, Alcoholism and Drug Addiction Limits
Inpatient coverage for nervous, mental and emotional disorders, including alcoholism and drug addiction, is limited to 30 days treatment for a covered person age 19 or older, or 45 days for a covered person under age 19 per year. Outpatient coverage is limited to $600 during any period of 12 consecutive months for these disorders.

Exclusions and Limitations
The Policy does not cover: injury or sickness resulting from war or act of war, whether war is declared or undeclared; intentionally self-inflicted injury; suicide or attempted suicide, whether sane or insane (in Missouri, while sane); 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: (1) for a Covered Spouse or Child of an Active Duty Member; (2) for each spouse or child’s travel out of the United States due to the Member’ s assignment; domiciliary or custodial care; eye refractions and routine eye exams except when rendered to a child up to 6 years from his or her birth; eyeglasses and contact lenses; prosthetic devices, except those covered by TRICARE; cosmetic procedures, except those resulting from Sickness or Injury while a Covered Person; hearing aids, orthopedic footwear; 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; drugs which do not require a prescription, except insulin; dental care unless such care is covered by TRICARE, and then only to the extent that TRICARE covers such care; any confinement, service, or supply that is not covered under TRICARE; Hospital nursery charges for a well newborn, except as specifically provided under TRICARE; any routine newborn care except Well Baby Care, as defined, for a child up to 6 years from his or her birth; expenses in excess of the TRICARE Cap; expenses which are paid in full by TRICARE; any expense or portion thereof applied to the TRICARE Outpatient Deductible, treatment for the prevention or cure of alcoholism or drug addiction except as specifically provided under TRICARE and this Policy; any part of a covered expense which the Covered Person is not legally obligated to pay because of payment by a TRICARE alternative program.

TRICARE Prime Supplement excludes the Point-of-Service Cost Share Amount.

This material explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this brochure and the contract, the terms of the contract apply. Complete details are in the Certificate of Insurance issued to each insured individual.

This program is not available in all states.

Administered By:

ASSOCIATION & SOCIETY INSURANCE CORPORATION
Administrator for Hartford Life Insurance Company

If you have questions about your TRICARE Supplement Insurance Plan, call our experts at:

1-800-638-2610 x255
(8:30 a.m. to 4:30 p.m. Eastern Time)
or
E-mail: CustSvc@asicorporation.com

Underwritten by: Hartford Life

Hartford Life is the 3^rd largest life insurance group in the U.S. based on assets.1 Our investment portfolio is of the highest quality, and our superior financial returns continue to earn strong stable ratings in the industry.

1 Based on year-end statutory asset data from Thomson Financial, 2000

Policy Form Number SRP-1269(HL)(5111)
Brochure Number SRH-3321-DQ