Page 30 - Demo

SUPPLEMENT-TYPE MEDICAL PLANS | Summary of Benefits | Continued
Supplement-Type Standard Plan
Supplement-Type Enhanced Plan
$0 for most exams and screenings, Medicare lists screenings that require deductible and coinsurance: https://www.medicare.gov/ coverage/preventive-screening-services.
Coverage for expenses incurred for physical exams, preventive screening tests and services and any other tests or preventive measures determined to be appropriate by the attending physician, not otherwise covered by Medicare: Maximum plan benefit of $120 per calendar year; member pays all expenses over $120 calendar year maximum.
Diabetes Self-Management Training: $0 copay; 10% coinsurance. Plan deductible applies.
$0 for most exams and screenings, Medicare lists screenings that require deductible and coinsurance: https://www.medicare.gov/ coverage/preventive-screening-services.
Coverage for expenses incurred for physical exams, preventive screening tests and services and any other tests or preventive measures determined to be appropriate by the attending physician, not otherwise covered by Medicare: Maximum plan benefit of $120 per calendar year; member pays all expenses over $120 calendar year maximum.
Diabetes Self-Management Training: Member pays $0.
10% coinsurance for each x-ray visit and/or simple diagnostic test, complex diagnostic test and/or radiology visit, deductible applies.
Member pays $0 for clinical lab services, blood tests, urinalysis.
Member pays $0.
10% coinsurance, deductible applies.
Non-emergency transportation must be medically necessary and supported by written order from a doctor.
Member pays $0.
Non-emergency transportation must be medically necessary and supported by written order from a doctor.
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.
30 | Insurance Trust For Delta Retirees | 2021 Benefits & Resources Guide
TRANSPORTATION DIAGNOSTIC SERVICES/ (MEDICALLY NECESSARY) LABS/IMAGING
PREVENTIVE CARE