Dear MOAA Member, Thank you for your interest in MOAA s MEDIPLUS TRICARE Supplement Insurance. I m pleased to send the information you requested.

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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 Supplement Insurance Plan teamed with TRICARE helps provide you and your family with stable, affordable and valuable health insurance protection. Dear MOAA Member, Thank you for your interest in MOAA s MEDIPLUS TRICARE Supplement Insurance. I m pleased to send the information you requested. MEDIPLUS the only TRICARE Supplement Insurance Plan endorsed by MOAA has been around for more than 40 years because of its valuable protection and affordable group rates. Today, more than 30,000 MOAA members (about 1 out of every 3 eligible MOAA members under age 65) have chosen MEDIPLUS for their family s health insurance needs. That s because MEDIPLUS offers you these advantages: Guaranteed acceptance*: MEDIPLUS is specifically designed for MOAA members and their families (It s not available to the general public). You, your spouse and dependent children cannot be turned down. Simply complete and return the enclosed form and you re in! Valuable Benefit: MEDIPLUS works with TRICARE Standard, Extra and Prime 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. Helps pick up the tab for excess charges: If you use doctors outside the TRICARE network and they charge you more than the TRICARE-allowed amount, MEDIPLUS will pay the difference up to 115% of the TRICARE-allowed amount. TSTND-LET-0315 ILI648L-040C9 1 Stock:

2 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 for six months. (If you switch to MEDIPLUS from employer-sponsored protection because you move, change jobs or retire, or if you leave Active Duty, 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, Cherie Zadlo Col, USAF (Ret) Director, Member Products and Services Timothy R. Weber, Partner Mercer Health & Benefits Administration LLC MOAA Insurance Plans Administrator License # 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 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. SRP-1269 ASN (1134) Copyright 2016 Mercer LLC. All rights reserved. Questions? Call toll-free :30 a.m. to 5:00 p.m. Central Time, Monday - Friday or us at moaa.service@mercer.com ILI648L-040C9 2

3 AGP C9-Q MEDIPLUS TRICARE SUPPLEMENT INSURANCE ENROLLMENT FORM Complete all information in ink. Endorsed by: 1. Please complete the following information: 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 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. Member Name: Address: City: State: Zip: Member Social Security Number: Date of Birth: Address: Sex: Rank/Service:* Daytime Phone: Are you retired from the military?* Yes No MOAA Member Number: Male mo yr Female Date of retirement (or initial eligibility for TRICARE benefits): Membership Type: (Check one) day MOAA Member mo day yr 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 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 within the past 12 months.) (Over, please) TSTND-ENR-0315 ILI648E-040C9 1 Stock:

4 2. Please select the MEDIPLUS TRICARE Supplement you want. (Continued) (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 within the past 12 months.) TRICARE PRIME Plan RETIRED PLAN Member Nonsmoker (PHT1) Smoker (PTS1) Spouse Nonsmoker (PHT5) Smoker (PTS5) Child(ren) If enrolling in the TRICARE Prime Supplement (or USFHP), please tell us the date your TRICARE Prime (or USFHP) protection started. Under age 21 (PHT7) (23 if a full-time student) mo day yr Age (PCT7) (if enrolled in TRICARE Young Adult) 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 day yr mo day yr mo day yr mo day 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. Then read, sign and date. Member (Note: The MOAA member should answer questions even if only requesting child coverage.) 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 60 days of termination of Active Duty service?... D. Are you enrolling within 30 days of initial eligibility for TRICARE benefits?... E. Are you changing from our TRICARE Prime Supplement to our TRICARE Standard Supplement on your Prime Anniversary Date or because you have moved outside of the Prime Network?... YES NO Spouse (if applying) YES NO ILI648E-040C9 2

5 5. 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 the MEDIPLUS TRICARE Prime Supplement does not provide a waiver of premium provision for my surviving insured spouse and/or children. I understand that eligibility to receive benefits under the TRICARE Retiree Supplement is dependent on my (or my deceased spouse's) entitlement to uniformed services retired pay. I have read the MEDIPLUS Acknowledgment and the "Important Notice About This Coverage" section of the MOAA MEDIPLUS Web site 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 2016 Mercer LLC. All rights reserved. ILI648E-040C9 3

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7 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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9 MEDIPLUS TRICARE Supplement Insurance Plan Summary of Benefits 1. Guaranteed Acceptance for You and Your Family As a member of MOAA under age 65, you and your family 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. 5. MEDIPLUS Offers Many Plan Options MEDIPLUS gives you a choice of different plans to provide you with the most flexible coverage. MEDIPLUS In- and Outpatient Plan Coverage that works with TRICARE Standard to help offer you and your family protection for Hospital bills, doctor bills and prescription drugs. If you re retired, you can decide between four deductible options for more flexibility ($150 per person/$300 per family, $250 per person/$500 per family, $300 per person/$600 per family, or $400 per person/$800 per family). Active Duty family members can take advantage of the In- and Outpatient Plan with no deductible. You can also enroll your spouse or children without enrolling yourself. Your spouse is eligible as long as he or she is under age 65 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). MEDIPLUS Retired Inpatient Only Plan TRICARE Standard Supplement protection if you just want coverage for expensive Hospital stays and certain outpatient surgeries. Evaluate your personal situation and choose the plan with no deductible or the $200 per person deductible option... whichever one works best for your family. 2. MEDIPLUS Teams with TRICARE MEDIPLUS and TRICARE work together to help pay your medical bills, like Hospital stays, doctor visits and prescription drugs. 3. MEDIPLUS Helps Reduce Covered 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. MEDIPLUS Retired TRICARE Prime Plan A program that works with TRICARE Prime to help reduce your out-of-pocket expenses. 6. Easy Conversion to MEDIPLUS from Other Coverage Switching from an employer health plan, from Active Duty or after your initial eligibility for TRICARE is easy. 4. Choose Your Own Doctor With MEDIPLUS, you re free to choose your own TRICARE-authorized doctor or specialist (with no referrals)... whenever you like. 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). TSTND-BRO-0315 ILI648P-040C9 1 Stock:

10 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. 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. Leaving Active Duty: When you enroll within 60 days of the date your Active Duty coverage ends, you and your family qualify for MEDIPLUS without the waiting period for current health conditions. This also applies if you enroll in MEDIPLUS within 30 days of your initial eligibility for TRICARE benefits. Your dependent s coverage will remain in effect as long as your coverage is active, premiums are paid and they meet the eligibility requirements. 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. Switching from the MEDIPLUS Retired TRICARE Prime Supplement to a MEDIPLUS TRICARE Standard Supplement: Current health conditions will be covered right away, as long as you ve had continuous MEDIPLUS coverage for at least six months and you discontinue TRICARE Prime on your Prime anniversary date or move out of network. MEDIPLUS covers all new health conditions right away. For current health conditions, the waiting period is six months. 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. If you discontinue TRICARE Prime on a date other than your anniversary date, current health conditions will be covered under your MEDIPLUS TRICARE Standard Supplement after six months. 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. 7. DirectClaim Electronic Filing of MEDIPLUS TRICARE Supplement Claims 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 % 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. 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. 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. Questions About This Coverage? Call: Visit: moaa.service@mercer.com Our hearing-impaired or voice-impaired members may call the Relay Line at MEDIPLUS TRICARE Standard Supplement Benefits Can Continue Premium-Free 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 Medicareeligible. Spouses of active duty members will be covered for up to 10 years or until they remarry, reach age 65 or qualify for Medicare. Administered by: Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box Des Moines, IA 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. (The waiver of premium benefit is not available under the MEDIPLUS TRICARE Prime Supplement). AR Insurance License # CA Insurance License #0G39709 In CA d/b/a Mercer Health & Benefits Insurance Services LLC Sponsored by: 9. Keep MEDIPLUS Wherever You Go MEDIPLUS is yours to keep even if you change jobs or move. The protection can stay with you when you leave; your MEDIPLUS protection will not be canceled due to claims or a 2 ILI648P-040C9

11 3.) suicide or attempted suicide, whether sane or 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 Hartford Life Insurance Company in ME, MD, MN, and MT, or child s travel out of the United States due to the Member s and Hartford Life and Accident Insurance Company in all assignment; 6.) domiciliary or custodial care; 7.) eye refractions and other states. Home office of both companies is Simsbury, routine eye exams except when rendered to a child up to 6 years from CT his or her birth; 8.) eyeglasses and contact lenses; 9.) prosthetic The Hartford is The Hartford Financial Services Group, Inc., devices, except those covered by TRICARE; 10.) cosmetic and its subsidiaries, including issuing companies Hartford Life procedures, except those resulting from Sickness or Injury while a and Accident Insurance Company and Hartford Life Insurance Covered Person; 11.) hearing aids; 12.) orthopedic footwear; 13.) care Company. for the mentally or physically incapacitated if: a) the care is required because of the mental or physical incapacitation; or b) the care is This fact sheet explains the general purpose of the insurance received by an Active Duty Member s child through the TRICARE described, but in no way changes or affects the Master Policy AGP-1134 (Policy Form #SRP-1269 ASN [1134]) as actually issued. Extended Care Health Option (ECHO); 14.) drugs which do not In the event of a discrepancy between this brochure and the policy, the require a prescription, except insulin; 15.) dental care unless such care is covered by TRICARE, and then only to the extent that terms of the policy apply. All benefits are subject to the terms and TRICARE covers such care; 16.) any confinement, service, or supply conditions of the policy. Policies underwritten by Hartford Life and Accident Insurance Company and Hartford Life Insurance Company that is not covered under TRICARE; 17.) Hospital nursery charges for a well newborn, except as specifically provided under TRICARE; detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in full or discontinued. Complete 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 details are in the Certificate of Insurance issued to the insured covered expense which the Covered Person is not legally obligated to individual and the Master Policy issued to the policyholder. This program may vary and may not be available to residents of all states. pay because of payment by a TRICARE alternative program; and 21.) any claim under more than one of the TRICARE Supplement Plans, Your association shares a financial interest in this program, which or under more than one Inpatient Benefit or more than one Outpatient benefits the entire membership. Benefit of the TRICARE Supplement Plans. If a claim is payable Copyright 2016 Mercer LLC. All rights reserved. under more than one of the stated Plans or Benefits, payment will only be made under the one that provides the highest coverage, Important Definitions subject to the Pre-Existing Conditions Limitation. 22.) any expense applied to the TRICARE Outpatient Deductible, TRICARE Qualified Hospital: A Hospital must be engaged primarily in medical care and treatment of sick and injured persons on an inpatient Point-of-Service Deductible, Retiree Inpatient Only Supplement basis, have full surgical facilities, be under the supervision of legally Deductible or Retiree Inpatient/Outpatient Supplement Deductible. qualified physicians, and provide 24-hour nursing services by R.N.s Nervous, Mental, and Emotional Disorder, Alcoholism and to qualify. A sanitarium operated by or certified by the First Church of Drug Addiction Limitations: The coverage provided under the Christ Scientist, Boston, Massachusetts, also qualifies. A TRICARE supplement does not cover inpatient treatment for mental, convalescent home; Skilled Nursing Facility; a place for rest, nervous, or emotional disorders in excess of 45 days if under age 19, custodial care or for the aged; or a place primarily caring for mental or in excess of 30 days if age 19 or older (or 90 days if approved by illness, drug addiction, or alcoholism does not qualify. In certain TRICARE Standard) in any one calendar year. Outpatient benefits for situations, an institution for the treatment of nervous, mental or such disorders are limited to $500 during any period of 12 emotional disorders is considered a Hospital under the MEDIPLUS consecutive months. In addition, for mental illness we will pay up to TRICARE supplements. Confined or Confinement means being an 150 days of inpatient care in a TRICARE-authorized Residential inpatient in a Hospital or Skilled Nursing Facility due to Sickness or Treatment Center for a covered dependent child up to age 21. Injury. Underwritten by: Important Information Regarding Veterans Administration (VA) Hospitals: TRICARE supplement insurance policies pay 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. 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. General Exclusions and Limitations: The complete listing of exclusions and limitations is cited in the policy and certificate. The major ones are listed. 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; ILI648P-040C9 3

12 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 Standard/Extra 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 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 $58.58 Spouse $40.04 $44.05 $71.00 $78.10 Under 45 $20.44 $23.22 $35.80 $ $25.07 $27.85 $43.93 $48.81 $30.64 $34.35 $53.69 $60.20 $34.35 $39.00 $60.20 $68.33 $42.04 $47.06 $74.55 Each Child $83.42 $13.93 $24.42 $300 Per Person Deductible $150 Per Person Deductible Age Nonsmoker Smoker Nonsmoker Smoker Under 45 $18.85 $20.04 $30.19 $32.09 Member/ $21.22 $23.57 $33.97 $37.74 Auxiliary $29.47 $31.84 $47.19 $50.96 Member $40.09 $42.44 $64.17 $67.95 $50.85 $55.94 $82.36 $90.59 Under 45 $25.94 $29.47 $41.52 $ $31.84 $35.37 $50.96 $56.62 $38.90 $43.63 $62.28 $69.83 $43.63 $49.52 $69.83 $79.27 $53.39 $59.76 $86.47 $96.76 Spouse Each Child $17.69 $28.31 In- and Outpatient Plans ActIve Duty No Deductible Age Nonsmoker Smoker Under 45 Member/ Auxiliary Member Not Applicable Under Spouse $12.81 $13.44 Each Child $11.25 For additional rates, please see next page. ILI648P-040C9 4

13 TRICARE Standard/Extra Supplements Monthly Rates*: Inpatient-Only Plans Retiree $200 Per Person Deductible No Deductible Age Nonsmoker Smoker Nonsmoker Smoker Member/ Under 50 $ 5.67 $ 5.95 $ 7.90 $ 8.30 Auxiliary $ 7.83 $ 8.22 $10.97 $11.50 Member $12.33 $12.95 $17.25 $18.12 $13.53 $14.22 $24.58 $25.82 Under 50 $ 6.28 $ 6.62 $ 9.78 $10.28 $ 8.78 $ 9.22 $13.17 $13.83 $13.82 $14.50 $19.95 $20.93 $14.26 $14.96 $23.88 Spouse Each Child $4.90 $25.08 $5.73 TRICARE Prime Supplements Monthly Rates*: Retiree Age Nonsmoker Smoker Under 50 $12.64 $13.27 Member or $19.29 $20.26 Spouse $22.78 $23.91 $29.12 $30.59 Each Child $16.43 *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. 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 (TRICARE Standard/TRICARE Prime), 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-040C9 5

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15 How the MEDIPLUS TRICARE Supplement Insurance Plan Teams Up With TRICARE Standard TRICARE Standard Pays: With Only TRICARE Standard You Pay: The MEDIPLUS Retired Inpatient-Only Plan with $200 Per Person Deductible Pays: The MEDIPLUS Retired Inpatient-Only Plan with No Deductible Pays: The MEDIPLUS Retired Inpatient and Outpatient Plan with Deductible Pays: 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 annual $200 per person deductible PLUS covered excess charges up to 15% above the amount TRICARE allows. The DRG daily cost-share amount or 25% of the bill, whichever is less, PLUS covered excess charges up to 15% above the amount TRICARE allows. 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 the annual $200 plan deductible PLUS covered excess charges up to 15% above the amount allowed by TRICARE. The remaining 25%* PLUS covered excess charges up to 15% above the amount allowed by TRICARE. The remaining 25%* after you meet the selected annual plan deductible PLUS covered excess charges up to 15% above the amount allowed by TRICARE. FOR INPATIENT CARE Government Hospital Nothing Current daily subsistence charges. Current daily subsistence charges. Current daily subsistence charges. Current daily subsistence charges. 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.** 25%* of the amount TRICARE allows for Outpatient Ambulatory Surgical Expenses for any covered procedures after the TRICARE deductible. Up to $500 a year. 25%* of the amount TRICARE allows for Outpatient Ambulatory Surgical Expenses for any covered procedures after the TRICARE deductible. Up to $500 a year. The remaining 25%* after the TRICARE outpatient deductible and selected plan deductible*** PLUS covered excess charges up to 15% above the amount TRICARE allows. OUTPATIENT 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 N/A N/A The prescription co-pay amount due for a 30-day supply after you meet the selected annual MEDIPLUS 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. N/A N/A The prescription co-pay amount due for a 90-day supply after you meet the selected annual MEDIPLUS 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. N/A N/A The prescription co-pay amount due for a 30-day supply after you meet the TRICARE outpatient deductible and the selected annual MEDIPLUS deductible. FOR INPATIENT CARE Civilian Hospital (Room, board, supplies, and staff services billed by the Hospital) FOR OUTPATIENT CARE (Doctor visits, clinics, outpatient surgeries) 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 that, 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 co-payments ($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 1 of each year.) 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 The Hartford 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. The Hartford is not liable for payment of these charges. The MEDIPLUS Active Duty Family Inpatient and Outpatient Plan with No Deductible Type of Care: Civilian Hospital (Inpatient) TRICARE Standard Pays: With TRICARE Standard Benefits Only You Must Pay: The MEDIPLUS Active Duty Plan Pays: All TRICARE Standard allowable amounts except the first $25 or current daily subsistence charges (whichever is greater). The first $25 or current daily subsistence charges (whichever is greater); PLUS up to 15% of all charges over the TRICARE Standard allowable amount.** The first $25 or current daily subsistence charges (whichever is greater); PLUS covered excess charges up to 15% above the TRICARE Standard-allowed amount. Nothing. Current daily subsistence charges. Current daily subsistence charges. 80% of TRICARE Standard allowable amounts after the annual TRICARE Standard outpatient deductible. The remaining 20%, the TRICARE Standard deductible and all costs over the TRICARE Standard-allowed amounts.** The remaining 20% after the TRICARE Standard deductible, PLUS covered excess charges up to 15% above the TRICARE Standard-allowed amount. Outpatient Prescription Drugs (From civilian TRICARE retail network pharmacy) The TRICARE-allowed amonut 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. (From TRICARE Mail Order Pharmacy) The TRICARE-allowed amonut 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. (From a non-network pharmacy) The TRICARE-allowed amonut 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. Government Hospital (Inpatient) Civilian Doctors, Clinics, etc. (Outpatient) TRICARE Prime information on back

16 How the MEDIPLUS TRICARE Supplement Insurance Plan Teams Up With Retired TRICARE Prime Service With TRICARE Prime Coverage You Owe MEDIPLUS Retired TRICARE Prime Supplement Pays You Pay Civilian Provider Outpatient Copay $12\visit $12\visit $0 Civilian Inpatient Copay $11/day $11/day $0 Prescription Drugs (From civilian TRICARE retail network pharmacy) 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. $0 (From TRICARE Mail Order Pharmacy) 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. $0 The Point-of-Service deductible, PLUS 50% of the TRICARE-allowed amount PLUS covered excess charges up to 15% above the amount TRICARE allows. 50% of the TRICARE-allowed amount PLUS covered excess charges up to 15% above the amount TRICARE allows. (From non-network pharmacy) The Point-of-Service deductible. If you decide to get care from a TRICARE-approved civilian doctor without getting a referral from your Primary Care Manager (commonly referred to as the TRICARE Point-of-Service Option), MEDIPLUS will pay part of your bill. Your MEDIPLUS TRICARE Prime protection will cover your cost-shares for inpatient and outpatient care after you meet the TRICARE Point-of-Service deductible. Plus MEDIPLUS will pay covered excess charges up to 15% above the TRICARE-allowed amount for these expenses. About the Claims Process DirectClaim: MOAA s electronic filing process for MEDIPLUS TRICARE Supplement claims. Filing MEDIPLUS claims is fast and easy with DirectClaim, another valuable benefit to MEDIPLUS. With DirectClaim, you will not have to complete MEDIPLUS claim paperwork after you access most of your eligible TRICARE benefits. Please be aware that some TRICARE Supplement claims cannot be processed electronically, such as any prescription claims and most skilled nursing or skilled nursing facility, nursing home claims and claims filed from overseas. For these, you will need to submit paper claim filings to MEDIPLUS. Claim forms are accessible on the MOAA Insurance Plans website at If a claim for service is submitted through DirectClaim and TRICARE has paid the provider(s) directly, any payment due under a MEDIPLUS TRICARE Standard Supplement will be paid directly to the provider(s). Under TRICARE Prime, most network providers require the patient s $12 co-pay at the time of the office visit, so the MEDIPLUS TRICARE Prime Supplement reimbursement of those Prime outpatient co-pays will be sent directly to the member. Only the Prime $12 co-pay for office visits will be reimbursed to the member. All other Prime co-pays will be reimbursed to the provider. 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. If you have any questions about DirectClaim, please call the MOAA Insurance Plans Administrator at or moaa.service@mercer.com. Some TRICARE supplement claims cannot be processed electronically, such as prescription claims and most skilled nursing or skilled nursing facility claims. For these, a paper claim form will need to be submitted to MEDIPLUS for processing. General Tips Note your Insurance Certificate Number on all of your claim paperwork: This number is vital for prompt, accurate claim processing. You can find your number on your billing notices, your MEDIPLUS claims Explanation of Benefits (EOB), or your MEDIPLUS identification card. There are several ways you can submit your claims: By mail to: MOAA Insurance Plans P.O. Box 9126 Des Moines, IA By to: moaa.service@mercer.com By fax to: Pharmacy/Prescription Claims: You do not need to send a TRICARE EOB form. However, please enclose a copy of the printout your pharmacy gives you at the time your prescription is filled. This document must include the following information: Patient Name Prescription Number Date Prescription Filled Name of Prescription Co-payment Amount Note your MEDIPLUS Insurance Certificate Number QUESTIONS? Call Sponsored By: Underwritten by: Underwritten by: Hartford Life Insurance Company in ME, MD, MN and MT, and Hartford Life and Accident Insurance in all other states. Home office for 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. Copyright 2016 Mercer LLC. All rights reserved. (Hearing-impaired or voice-impaired members may call the Relay Line at ) moaa.service@mercer.com or visit 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 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.