Yudu - 2015 10 October

Monthly Group Rates MEDIPLUS®

TRICARE Standard Retiree Supplement Monthly Rates Under 45 45–49 50–54 55–59 60–64

Inpatient Member Nonsmoker $14.86 $16.71 $23.22 $31.58 $40.04 and

(or Auxiliary

Outpatient Member) Smoker $15.78 $18.56 $25.07 $33.42 $44.05 Each Plan

— $400

Per Person Spouse Deductible

(or Auxiliary Child

Nonsmoker $20.44 $25.07 $30.64 $34.35 $42.04 $13.93 Smoker $23.22 $27.85 $34.35 $39.00 $47.06

Inpatient Member Nonsmoker $26.03 $29.29 $40.68 $55.32 $71.00 and

Outpatient Member) Smoker $27.66 $32.54 $43.93 $58.58 $78.10 Each Plan

— $250

Per Person Spouse Deductible

Smoker Child

Nonsmoker $35.80 $43.93 $53.69 $60.20 $74.55 $24.42 $40.68 $48.81 $60.20 $68.33 $83.42

You qualify as a nonsmoker if you have not smoked cigarettes, cigars, or used a pipe, chewing tobacco, nicotine product or snuff in the past 12 months.

Switching To MEDIPLUS From Other Plans? Employer Plans: You won’t have to satisfy a waiting period on current health conditions if you sign up for MEDIPLUS within 30 days after your employer-sponsored protection ends because you are no longer an eligible participant in that program (if you change jobs, move or retire, for example). If you’ve voluntarily ended your employer- sponsored plan while you are still an eligible participant, the six-month waiting period for current health conditions will apply. Active Duty: Officers who enroll within 60 days of the date their active duty medical coverage ends or within 30 days of their initial eligibility for TRICARE benefits are also covered for all health conditions right away.

30-Day, No-Obligation Coverage: If for any reason you are not completely satisfied with your MEDIPLUS Certificate of Insurance after you have examined it for 30 days, you may cancel it with no questions asked. Simply write “Cancel” on your Certificate and return it within 30 days to MOAA Insurance Plans. Any claims paid under the Policy during the initial 30-day period will be deducted from the refund. Effective Date: Your MEDIPLUS coverage begins on the first day of the month following receipt of your Enrollment Form and first premium payment, provided you are a member of MOAA. Qualified Hospital: A Hospital must be engaged primarily in medical care and treatment of sick and injured persons on an inpatient basis, have full surgical facilities, be under the supervision of legally qualified physicians and provide 24-hour nursing services by R.N.s to qualify. A sanitarium operated by or certified by the First Church of Christ Scientist, Boston, Massachusetts, also qualifies. A convalescent home; skilled nursing facility; a place for rest, custodial care or care for the aged; or a place primarily caring for mental illness, drug addiction or alcoholism does not qualify. In certain situations, an institution for the treatment of nervous, mental or emotional disorders is considered a Hospital under the MEDIPLUS TRICARE Standard Supplements. Confined or Confinement means being an inpatient in a Hospital or Skilled Nursing Facility due to sickness or injury. Termination: Your coverage, as well as your dependents’ coverage, will terminate only if you are no longer eligible for TRICARE, the Master Policy is canceled, your premiums are not paid or you discontinue your MOAA membership. Your dependent children’s coverage will continue as long as they maintain TRICARE eligibility, are unmarried and are under age 21 (23 if full-time student or 26 if enrolled in TRICARE Young Adult). Spouse coverage will continue as long as he/she remains married to the MOAA member. General Exclusions and Limitations: These TRICARE Supplements do not cover: injury or sickness resulting from war or acts of war, whether declared or undeclared; intentionally self-inflicted injury; suicide or attempted suicide, whether sane or insane (in Missouri while sane); the following services: a) routine physical exams, except when such services are rendered to a child who is less than 6 years of age or when required for school enrollment (but not sports physicals) for a covered child ages 5 through 11; b) routine or well baby care and immunizations, except that these services are covered when rendered to a child who is less than 6 years of age; hospital nursery charges for a well newborn; domiciliary or custodial care; eye refractions and routine eye exams, unless required for school; eyeglasses and contact lenses (except that surgically implanted contact lenses are covered if approved by TRICARE); prosthesis (except that artificial limbs and eyes, and devices which must be implanted by surgery, are covered); breast implants except when covered by TRICARE for reconstructive surgery due to

cancer; 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 Persons with Disabilities” under TRICARE; nursing service, unless it is for the full-time service of a registered graduate nurse or a licensed practical nurse; purchase of a wheelchair, Hospital type bed, iron lung or other durable equipment unless approved by TRICARE (the rental of such equipment is covered); ambulance service in excess of $100 per trip unless approved by TRICARE; any expenses paid in full by TRICARE; drugs which do not require a prescription (except that insulin is covered); dental care, except that it is covered when it is needed to treat another (not dental) injury or sickness; any confinement, service, or supply that is not covered under TRICARE; any expense applied to the TRICARE Outpatient Deductible or the TRICARE Prime Point-of-Service Deductible; any expense applied to the Retiree Inpatient Only Supplement $200 Deductible; any expense applied to the Retiree Inpatient/Outpatient Supplement $400/$250 per person Deductibles; any portion of the cost-share amount which the Insured Person is not legally obligated to pay because of payment by a TRICARE alternative program; expenses for which TRICARE makes full payment for the TRICARE-allowed amount (this exclusion does not apply to coverage expressly provided for expenses in excess of the TRICARE allowable amount); any portion of a TRICARE cost-share which we determine is payable by TRICARE because the TRICARE cap has been met; under the Inpatient Only Plans, outpatient surgical benefits are limited to $500 a year. Nervous, Mental, Emotional Disorders, Alcoholism and Drug Addiction Limitations: The coverage provided under the TRICARE Supplement does not cover inpatient treatment for mental, nervous, or emotional disorders in excess of 45 days if under age 19, or in excess of 30 days if age 19 or older (or 90 days if approved by TRICARE Standard) in any one calendar year. Outpatient benefits for such disorders are limited to $500 during any period of 12 consecutive months. In addition, for mental illness we will pay up to 150 days of inpatient care for covered expenses for a covered dependent child up to age 21. 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 the coverage takes effect, that health condition won’t be covered until the person has been enrolled in the plan for six months. We urge you to consider this limitation before dropping any other health insurance you may have. 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’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. The Hartford is not liable for payment of these charges.

This brochure explains the general purpose of the insurance described, but in no way changes or affects the Master Policy (Policy # AGP-1134; Policy Form #SRP-1269 ASN [1134]) as actually issued. In the event of a

MEDIPLUS®

Member or Spouse Age

Under 50 50–54 55–59 60–64

Retired

TRICARE Prime Supplement Nonsmoker

$12.64 $19.29 $22.78 $29.12

Each Child — $16.43

Other MEDIPLUS TRICARE Standard Supplement Plans are available. For more information, call TOLL-FREE 1-800-247-2192. Premiums are based on each person’s age when coverage becomes effective. Premiums will increase as you enter a new age category. Premiums may be increased or decreased on a class-wide basis. For your convenience, you will be billed quarterly.

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 Insurance Company and Hartford Life and Accident 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, MOAA. This program may vary and may not be available to residents of all states.

About Our Role and Compensation In this transaction, Mercer Consumer, a service of Mercer Health & Benefits Administration LLC, is acting as the exclusive insurance agent and program manager for Hartford Life and Accident Insurance Company (Insurer) for this type of coverage, and not as your insurance broker. As the agent for Insurer, Mercer Consumer may provide these services: enrollments, ongoing servicing, billing, marketing, customer administrative and claim servicing and communications. In accordance with industry custom, we are compensated through commissions that are calculated as a percentage of the insurance premiums charged by insurers. We may also receive additional monetary and nonmonetary compensation from insurers or from other insurance intermediaries, which may be contingent upon such factors as volume, growth or retention of business. This compensation may include payment from insurers for marketing- related expenses or investments in technology. Our compensation may vary depending on the type of insurance purchased and the insurer selected. We will provide you additional information about our compensation upon your request. You may obtain this information by referring to https://www.personal-plans.com/disclosure and entering the security code i674009 or call us at 1-888-206-5088 for specific details.

AR Ins. Lic. #100102691, CA Ins. Lic. #0G39709 In CA d/b/a Mercer Health & Benefits Insurance Services LLC

Your association shares a financial interest in this program that benefits the entire membership.

Underwritten by: Hartford Life Insurance Company in ME, MN and MT, and Hartford Life and Accident Insurance Company in all other states. Home office for both companies is Simsbury, CT.

The Hartford®

is The Hartford Financial Services Group, Inc., and its

Smoker $13.27 $20.26 $23.91 $30.59

StaRting at $14.86i