Page 32 - Demo

SUPPLEMENT-TYPE MEDICAL PLANS | Summary of Benefits | Continued
Supplement-Type Standard Plan
Supplement-Type Enhanced Plan
10% coinsurance for Medicare-covered Part B drugs, deductible applies.
Member pays $0 for the pneumonia, influenza, hepatitis B, or other Medicare-covered vaccines.
Member pays $0.
Member pays $0 for the pneumonia, influenza, hepatitis B, or other Medicare-covered vaccines
10% coinsurance, deductible applies.
Member pays $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.
*Hearing services refer to Medicare-covered basic diagnostic hearing and balance exams; to determine if you need medical treatment, and these services are furnished by a physician, audiologist, or other qualified provider.
*Dental services refer to non-routine Medicare-covered services and are limited to: surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician.
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.
10% coinsurance, deductible applies.
Member pays $0.
32 | Insurance Trust For Delta Retirees | 2021 Benefits & Resources Guide
DENTAL HEARING MENTAL HEALTH: MENTAL HEALTH: PART B SERVICES* SERVICES* INPATIENT OUTPATIENT DRUGS