BENEFITS
SUMMARY CHART
See how our USBA TRICARE Supplement plans work with your TRICARE
Standard/Extra coverage |
| Care
Required |
TRICARE
Standard/Extra Pays |
Your TRICARE Standard/Extra Supplement Pays |
| Inpatient
care in civilian hospitals for RETIREES and dependent family
members (room, board, supplies, and staff services billed by
the hospital) |
The
TRICARE Standard/DRG amount (contracted rate for TRICARE Extra)
minus your cost share. |
Comprehensive
Plan & High Option II Plan - The lesser of $512/day
or 25% of billed amount, not to exceed the TRICARE Standard
DRG amount (lesser of $250/day or 25% cost share** of the contracted
rate for TRICARE Extra) PLUS 100% of covered excess charges
up to the reasonable and customary community standard level
(after you satisfy the fiscal year plan deductible.) |
| Inpatient
care in civilian hospitals for RETIREES and dependent family
members (doctors & other inpatient services not billed by the
hospital) |
75%
of the TRICARE Standard allowed amount (80% for TRICARE Extra)
for doctors and other professional services. |
Comprehensive
Plan & High Option II Plan - Your cost share**
PLUS 100% of covered excess charges up to the reasonable and
customary community standard level. |
| Inpatient
care in military hospitals |
All
but the daily subsistence fee. |
All
Plans - The daily subsistence fee. |
| Outpatient
care for RETIREES and dependent family members (office visits,
clinics, lab, prescription drugs, etc.) |
75%
of the TRICARE Standard allowed amount (80% for TRICARE Extra)
after you pay the TRICARE outpatient deductible. |
Comprehensive
Plan –
After you satisfy the fiscal year plan deductible of $75 per
person, and $150 family maximum, the plan will reimburse you
(1) the Tricare fiscal year outpatient deductible of $150
per person and $300 family maximum, *(2) your cost share**
and (3) 100% of covered excess charges up to the reasonable
and customary community standard level.
High
Option II Plan - Your cost share** PLUS 100% of covered
excess charges up to the reasonable and customary community
standard level. AFTER you pay the fiscal year plan deductible
of $150 per person $300 family maximum.* |
| Inpatient
care in civilian hospitals for ACTIVE DUTY dependents |
All
allowable charges except daily subsistence fee or $25, whichever
is greater. |
Active
Duty Plan - $25 or the daily subsistence fee, whichever
is greater, PLUS 100% of covered excess charges up to the reasonable
and customary community standard level. |
Outpatient
care for ACTIVE DUTY dependents (office visits, clinics, lab,
prescription drugs, etc.)
|
80%
of the TRICARE Standard Allowed amount (85% for TRICARE Extra)
after you pay the TRICARE outpatient Deductible. |
Active
Duty Plan - Your cost share** PLUS 100% of covered
excess charges up to the reasonable and customary community
standard level, AFTER you pay the Tricare Extra Standard Outpatient
Deductible. |
