Page 31 - Demo

SUPPLEMENT-TYPE MEDICAL PLANS | Summary of Benefits | Continued
Supplement-Type Standard Plan
Supplement-Type Enhanced Plan
10% coinsurance, deductible applies.
Member pays $0.
*Medical Supplies refers to Medicare Part B - covered durable medical equipment and supplies, including diabetes testing equipment and supplies.
10% coinsurance, deductible applies.
Member pays $0.
10% coinsurance, deductible applies.
Member pays $0.
Member pays $0.
Member pays $0.
$250 annual deductible.
Member pays 20% of expenses incurred for emergency care during the first 60 days of each trip. Lifetime maximum of $100,000. Member pays 100% thereafter.
After the plan pays benefits for foreign travel emergency and urgently needed services, you are responsible for the remaining cost.
Emergency or urgently needed care services while traveling outside the United States or its territories during a temporary absence of less than six months.
Member pays $0 of expenses incurred for emergency care during the first 60 days of each trip. Lifetime maximum of $100,000. Member pays 100% thereafter.
After the plan pays benefits for foreign travel emergency and urgently needed services, you are responsible for the remaining cost.
Emergency or urgently needed care services while traveling outside the United States or its territories during a temporary absence of less than six months.
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 | 31
FOREIGN TRAVEL HOSPICE AMBULANCE PHYSICAL MEDICAL EMERGENCY CARE CARE THERAPY SUPPLIES*