Dd Form 2494 1 – Fill Out and Use This PDF

SUPPLEMENTAL TRICARE - ACTIVE DUTY FAMILY MEMBER DENTAL PLAN (FMDP)

ENROLLMENT ELECTION

CONDITIONS

This f orm should only be complet ed w hen:

(1) Family members are residing in t w o or more physically separat e locat ions, and only t he f amily members in one or more of t he locat ions are t o be enrolled; or

(2)There are no f amily members age f our (4) or older and more t han one (1) f amily member under age f our (4) and t he sponsor elect s t o enroll t he eldest f amily member; or

(3)A sponsor w it h enrolled f amily members elect s t o disenroll some, but not all, enrolled f amily members based on t he enrollment except ions list ed below .

INSTRUCTIONS

IMPORTANT: FMDP ENROLLMENT AND CLAIMS PAYMENT IS BASED UPON DEERS ELIGIBILITY FOR CHAMPUS. WHEN ENROLLING OR CHANGING FMDP ENROLLMENT, MAKE SURE YOUR DEERS INFORMATION IS CORRECT. EXPIRED ID CARDS WILL AFFECT YOUR CHAMPUS (and Dental) ELIGIBILITY. CHECK YOUR FAMILY MEMBERS' ID CARD.

NOTE: CHANGES IN FAMILY STATUS (gains and losses) THAT AFFECT YOUR DENTAL PREMIUM MUST BE REPORTED TO DEERS USING DD FORM 1172, " Applicat ion f or Unif ormed Services Ident if icat ion Card - DEERS Enrollment ."

FMDP Enrollment is f or a minimum of t w o (2) years, unless:

(1) Family members lose t heir CHAMPUS eligibilit y in DEERS; or

(2) Sponsor and f amily members t ransf er OCONUS t o an area w here FMDP is not available and t he sponsor volunt arily elect s t o disenroll all enrolled f amily members; or

(3)Sponsor and enrolled f amily members t ransf er t o a unif ormed services inst allat ion t hat of f ers space available f amily member dent al care; or

(4) Sponsor and f amily members are ret urning f rom an overseas locat ion w here FMDP is not available and t he sponsor has bet w een 12 and 23 mont hs remaining in t he unif ormed service.

A copy of the completed form must be mailed to: DEERS Support Office, ATTN: DN99, 2511 Garden Road, Monterey, CA 93940 -5330 . The DEERS Support Of f ice w ill send t he sponsor a let t er conf irming receipt and processing of t he f orm.

REMINDER: The FMDP is a " prepaid" plan, w hich means deduct ions f rom your pay must be made in advance of coverage. Coverage f or enrolled CHAMPUS eligible f amily members shall begin t he f irst day of t he mont h f ollow ing receipt of t his f orm by your personnel act ivit y. For example, if t he f orm is complet ed in January, coverage begins February 1. How ever, it is import ant t o not e t hat processing of t he enrollment inf ormat ion may t ake 30 days or more. This means t hat even t hough f amily members are eligible f or coverage, a premium deduct ion may not appear on your LES during t he f irst or second mont h of enrollment . Premium deduct ions w ill be made ret roact ive t o t he mont h t he f orm w as complet ed. It also means t hat t he cont ract or may not be able t o conf irm eligibilit y if f amily members visit a dent ist soon af t er t hey are enrolled.

Claims f or enrolled f amily members cannot be paid by t he cont ract or unt il enrollment inf ormat ion is received f rom t he government . If a claim is denied because t he cont ract or cannot verif y eligibilit y, t hat does not necessarily mean t hese services w ill not be covered. Once eligibilit y verif icat ion has been received, t he f amily member or dent ist can request reprocessing of t he denied claim by calling or w rit ing t he cont ract or.

SECTION I - ACTIVE DUTY MEMBER ELIGIBILITY INFORMATION

SPONSORS WITH 12 TO 23 MONTHS RETENTION RETURNING FROM AN OCONUS AREA WHERE FMDP WAS NOT AVAILABLE:

NOTE: These enrollment codes may only be used f or sponsors enrolling f amily members ret urning f rom an OCONUS area w here FMDP w as not available. If t he f amily members did not accompany t he sponsor on t he OCONUS t our, t he sponsor may not enroll t he f amily members.

complet e a new enrollment f orm if I w ant t o change t he enrollment st at us of my f amily members (such as adding family members not listed on this form). I also underst and I may not t erminat e enrollment based on a change in f amily size. If my DEERS record indicat es a f amily member is no longer eligible, a change w ill occur aut omat ically w it h no act ion on my part . I f urt her underst and t hat t he premium rat e f or t his program is subject t o change. I also underst and t hat during t he t w o year minimum enrollment period I cannot disenroll due t o a change in premium rat e. I underst and t hat enrollment in FMDP aut omat ically t erminat es t he last day of t he mont h of act ive dut y or upon terminat ion of basic pay. I aut horize payroll deduct ions t o be t aken f rom my pay based upon t he inf ormat ion in DEERS and my coverage elect ion specif ied above.

DD Form 2494 -1 (BACK), SEP 95