Page 34 - Demo

MEDICARE ADVANTAGE MEDICAL PLANS | Summary of Benefits
Medicare Advantage Standard Plan
Medicare Advantage Enhanced Plan
Medicare Advantage Enhanced Plus
$750
Deductible applies to covered services within each category following, prior to the copay or coinsurance, if any, being applied, unless otherwise noted.
$0
$0
$2,500
All copays, 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.
$2,500
All copays and coinsurance 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.
$1,500
All copays and coinsurance 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.
$250 copay per day for days 1-5 per admission; then covered 100% by the plan.
No limit to the number of days covered by the plan. $0 copay for physician services received while an inpatient during a hospital stay.
$95 copay per day for days 1-5 per admission; then covered 100% by the plan.
No limit to the number of days covered by the plan. $0 copay for physician services received while an inpatient during a hospital stay.
$0 copay per admission, covered 100% by the plan.
No limit to the number of days covered by the plan. $0 copay for physician services received while an inpatient during a hospital stay.
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.
34 | Insurance Trust For Delta Retirees | 2021 Benefits & Resources Guide
INPATIENT HOSPITAL COVERAGE
MAXIMUM ANNUAL CALENDAR YEAR OUT OF POCKET DEDUCTIBLE