Page 40 - Demo

MEDICARE ADVANTAGE MEDICAL PLANS | Summary of Benefits | Continued
Medicare Advantage Standard Plan
Medicare Advantage Enhanced Plan
Medicare Advantage Enhanced Plus
$5 copay per visit to a Primary Care Physician (PCP) or retail health clinic.
$40 copay per visit to a specialist.
$10 copay per visit to a Primary Care Physician (PCP) or retail health clinic.
$25 copay per visit to a specialist.
10% coinsurance per visit to a Primary Care Physician (PCP) or retail health clinic.
10% coinsurance per visit to a specialist.
*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.
$5 copay for visits to a primary care physician for exams to diagnose and treat diseases of the eye.
$40 copay for visits to a specialist for exams to diagnose and treat diseases of the eye.
$0 copay for glaucoma
and diabetic retinopathy screenings. Deductible does not apply.
10% coinsurance for glasses/ contacts following cataract surgery.
$10 copay for visits to a primary care physician for exams to diagnose and treat diseases of the eye.
$25 copay for visits to a specialist for exams to diagnose and treat diseases of the eye.
$0 copay for glaucoma and diabetic retinopathy screenings.
10% coinsurance for glasses/ contacts following cataract surgery.
10% coinsurance for visits to a primary care physician for exams to diagnose and treat diseases of the eye.
10% coinsurance for visits to a specialist for exams to diagnose and treat diseases of the eye.
$0 copay for glaucoma and diabetic retinopathy screenings.
10% coinsurance for glasses/ contacts following cataract surgery.
*Eye health refers to glaucoma screenings for high risk members, diabetic retinopathy screening, macular degeneration tests and treatment, and eye protheses (replacement covered once every five years).
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.
40 | Insurance Trust For Delta Retirees | 2021 Benefits & Resources Guide
EYE HEALTH*
DENTAL SERVICES*