Page 37 - Demo

MEDICARE ADVANTAGE MEDICAL PLANS | Summary of Benefits | Continued
Medicare Advantage Standard Plan
Medicare Advantage Enhanced Plan
Medicare Advantage Enhanced Plus
Non-emergency transportation is covered at 10% coinsurance with prior authorization from the plan.
Non-emergency transportation is covered at 10% coinsurance with prior authorization from the plan.
Non-emergency transportation is covered at 10% coinsurance with prior authorization from the plan.
10% coinsurance.
10% coinsurance.
10% coinsurance.
*Medical Supplies refers to Medicare Part B - covered durable medical equipment and supplies, including diabetes testing equipment and supplies.
$40 copay for physical therapy, occupational therapy, and speech language therapy visits.
Your provider must obtain approval before receiving services. This is called getting prior authorization.
$25 copay for physical therapy, occupational therapy, and speech language therapy visits.
Your provider must obtain approval before receiving services. This is called getting prior authorization.
10% coinsurance.
10% coinsurance per one-way trip.
Your provider must obtain approval before non- emergency ground, air, or water transportation. This is called getting prior authorization.
10% coinsurance per one-way trip.
Your provider must obtain approval before non- emergency ground, air, or water transportation. This is called getting prior authorization.
10% coinsurance per one-way trip.
Your provider must obtain approval before non- emergency ground, air, or water transportation.
If your Medical Plan has a deductible, it must be met before copayments or coinsurance will apply. See page 42 for details regarding Prescription Drug Plan deductible, copays and coinsurance.
Insurance Trust For Delta Retirees | 2021 Benefits & Resources Guide | 37
AMBULANCE
PHYSICAL THERAPY
MEDICAL TRANSPORTATION SUPPLIES* (MEDICALLY NECESSARY)