Supplement Plan Enrollment Form (Page 2 of 3) in pdf

The following chart is an example of what the

TRICARE Prime Supplement

pays for some of the most common types of

services. Refer to your

TRICARE Prime

Handbook for a more complete description of terms and conditions under TRICARE.

Care Required

TRICARE Prime Pays

Your TRICARE Prime Supplement Pays

All except the following:

Per Visit/Service:

Civilian Outpatient Care

Per Visit:

$12

Ofﬁ ce

$12

$30

Emergency Room

$30

Outpatient Mental Health

$25

Individual

$25

Individual

$17

Group

$17

Group

Civilian Inpatient Admission

$11 per day

($25 minimum per admission)

Inpatient Mental Health

$40 per day

$40

Ambulance Service

$20

Outpatient Ambulatory Surgery

$25

Prescription Drugs

Generic

Brand Name

$22

Non-Formulary

$22

Non-Formulary

BUDGET YOUR

PAYMENTS WITH

CHECKOMATIC...

THE DIRECT MONTHLY

PAYMENT PLAN

Your TRICARE Supplement Plan premiums

can be deducted directly from your checking

account every month... with no worries about

missing a payment and losing your valuable

insurance protection. Simply complete the

As a convenience to me, I request and authorize Association & Society Insurance Corporation or another Transamerica Financial Life Insurance Company

Request and Authorization form at the right.

administrator/representative to initiate electronic debit entries each month and charge them to my checking account as indicated above. Authority to charge

Enclose a blank check (marked VOID) to

such debits to my account shall become eff ective as of the date this authorization is signed and shall remain in eff ect until revoked by me in writing.

be kept on fi le. All future premiums will

I agree that the bank’s rights, with respect to each debit, shall be the same as if it were drawn and signed by me. I further agree that, should any debit be

be deducted from your checking account

dishonored, whether with or without cause, the bank shall be under no liability whatsoever, even though such dishonor results in the termination of insurance.

automatically on the fi rst business day of

each month. Completed form and void

check must be received by the 15th of the

month prior to the month of deduction.

RAUS 183-9/10