Page 35 - Demo

MEDICARE ADVANTAGE MEDICAL PLANS | Summary of Benefits | Continued
Medicare Advantage Standard Plan
Medicare Advantage Enhanced Plan
Medicare Advantage Enhanced Plus
Surgical: $100 copay for each outpatient hospital facility or ambulatory surgical center visit for surgery.
Non-surgical: $5 copay for a visit to a primary care physician in an outpatient hospital setting/clinic for non-surgical services.
$40 copay for a visit to a specialist in an outpatient hospital setting/clinic for non- surgical services including radiation therapy.
For both surgical and non- surgical: $100 copay for each outpatient observation room visit.
Surgical: $100 copay for each outpatient hospital facility or ambulatory surgical center visit for surgery.
Non-surgical: $10 copay for a visit to a primary care physician in an outpatient hospital setting/clinic for non-surgical services.
$25 copay for a visit to a specialist in an outpatient hospital setting/clinic for non- surgical services including radiation therapy.
For both surgical and non- surgical: $100 copay for each outpatient observation room visit.
10% coinsurance
$5 copay per visit to a Primary Care Physician (PCP) or retail health clinic.
$40 copay per visit to a specialist.
10% coinsurance for allergy testing and allergy injections.
$10 copay per visit to a Primary Care Physician (PCP) or retail health clinic.
$25 copay per visit to a specialist.
10% coinsurance for allergy testing and allergy injections.
10% coinsurance
$75 copay for each emergency room visit.
$75 copay for each emergency room visit.
$100 copay for each emergency room visit.
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 | 35
EMERGENCY DOCTOR VISITS OUTPATIENT HOSPITAL CARE (PRIMARY & SPECIALISTS) COVERAGE