Exclusions and Limitations

Pre-Existing Condition Limitation
Any injury or sickness, whether diagnosed or undiagnosed for which any person proposed for coverage received medical treatment or care within the 6 month period preceding the effective date of enrollment will not be covered until the coverage has been in effect for 6 months. However, new conditions will be covered immediately.

Exclusions
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, 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:
(1) 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 his or her 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 Sickness or Injury while a Covered Person;
10. hearing aids;
11. orthopedic footwear;
12. 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;
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 his or her 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. that part of any Covered Excess Charges except as otherwise stated in the Supplement Benefits;
22. treatment for the prevention or cure of alcoholism or drug addiction except as specifically provided under TRICARE and the Policy;
23. 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
24. 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.

Nervous, Mental, Emotional Disorder, Alcoholism and Drug Addiction Limits
The coverage provided under the Inpatient Benefit of the TRICARE Supplement Plan for nervous, mental and emotional disorders, including alcoholism and drug addiction, is limited to:
a) 30 Inpatient treatment days for a Covered Person age 19 or older; or
b) 45 Inpatient treatment days for a Covered Person under age 19; per Fiscal Year.
This Inpatient limit is based on the number of days TRICARE normally provides each Fiscal Year for such confinements. In rare instances, TRICARE extends these daily limits. If this occurs, we will limit the number of days that we provide for such confinement to the lesser of:
a) the number of days TRICARE pays for such Inpatient treatment during the Fiscal Year; or
b) 90 Inpatient days per Fiscal Year.
The coverage provided under the Outpatient Benefit of the TRICARE Supplement plan for:
a) nervous, mental, and emotional disorders; and
b) alcoholism and drug addiction;
is limited to $500 during any Fiscal Year for all such disorders.

Termination
Insured Person Termination: The Insured Person's 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 he or she ceases to be a Member;
4) the first day of the month on or next following the date he or she ceases to be eligible for the Plan under which he or she is covered;
5) the date we or the group cancel coverage for a Class of Eligible Person to which he or she belongs;
6) the date the Member attains age 65;
7) the date he or she becomes eligible for Medicare, if under age 65 at time of Medicare eligibility.

Termination of an Insured Person's insurance will not prejudice any claim which occurred before the effective date of termination.

Dependent Termination: The dependent's coverage under the Policy will cease on the first to occur of:
- the date the Policy terminates, or the date the Organization ceases to be a Participating Organization of the Policyholder;
- the date the required premium is not paid, subject to the Grace Period provision;
- the first day of the month on or next following the date he or she ceases to be an Eligible Spouse or an Eligible Child;
- the first day of the month on or next following the date he or she ceases to be eligible for the Plan under which he or she is covered;
- the date we or the group cancel coverage for a Class of Eligible Person to which he or she belongs;
- the date he or she ceases to be covered under TRICARE;
- the date he or she becomes eligible for Medicare;
- the date the Member ceases to be covered, subject to the Covered Dependent’s Continuation Provision; (This will not apply to the Spouse or Child of an Active Duty Member or a Service Disabled Member.)
- if a Spouse, the date he/she attains age 65.

Termination of Covered Dependent's coverage will be without prejudice to any claim which occurred before the effective date of termination.

Non-Duplication of Coverage under Employer Health Program
If a claim payable under the Policy is also payable under an Employer Health Program with TRICARE as the secondary payor, we will limit our 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.

Change of Policy Premiums
We have 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.


Ref #22365852