Page 28 - Demo

SUPPLEMENT-TYPE MEDICAL PLANS | Summary of Benefits
Supplement-Type Standard Plan
Supplement-Type Enhanced Plan
$300
Only applies to Part B services, and must be satisfied before any Medicare Part B benefits are paid. The Medicare Part B deductible is included in this $300 calendar year deductible.
Note: Plan pays entire Medicare Part A deductible; member pays $0 of Medicare Part A deductible.
$0
$1,500
Only applies to Part B services. All Part B coinsurance and deductible amounts accrue towards the medical plan maximum annual out- of-pocket amount, with the exception of the foreign travel emergency and urgently needed care deductible or coinsurance amounts.
$0
$0 copay until 365 days, member pays 100% of all charges beyond 365 days.
$0 copay until 365 days, member pays 100% of all charges beyond 365 days.
10% coinsurance, deductible applies.
Member pays $0.
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.
28 | Insurance Trust For Delta Retirees | 2021 Benefits & Resources Guide
OUTPATIENT HOSPITAL INPATIENT HOSPITAL MAXIMUM ANNUAL CALENDAR YEAR COVERAGE COVERAGE OUT OF POCKET DEDUCTIBLE