Delta Airlines 2011 Annual Report Download - page 133
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Exhibit A
Diamond HSA Medical Option Overview
Services and supplies eligible for coverage must be provided for the purpose of preventing, diagnosing or treating a sickness, injury, disease or symptom, and
meet certain established criteria. If eligible for Medicare, Medicare is primary and the medical option described here is secondary. This means that this option
pays the difference between what this option would have paid had it been primary (after deductible and out-of-pocket maximums are met) and the amount
Medicare pays.
2012 Diamond HSA Medical Option
Network Non-Network
Annual Deductible
Employee Only $2,300 $4,600
Employee & Spouse (Individual/Family) $2,300/$3,500 $4,600/$7,000
Employee & Child(ren) (Individual/Family) $2,300/$3,500 $4,600/$7,000
Family (Individual/Family) $2,300/$4,500 $4,600/$9,000
Coinsurance (% paid by plan) Plan pays 90% after Deductible Plan pays 60% of 140% of Medicare
Reimbursement Rate after Deductible (Maximum
Non-Network Reimbursement Program (MNRP)
rate (also called the Medicare Reimbursement
Rate). A Medicare-allowable charge is what the
federal Medicare program would allow as a
covered expense).
Annual Coinsurance Maximum (Includes Behavioral Health/Substance Abuse and Prescription Drug Benefits; Excludes the Deductible)
Employee Only $500 $4,600
Employee & Spouse (Individual/Family) $500/$1,000 $4,600/$7,000
Employee & Child(ren) (Individual/Family) $500/$1,000 $4,600/$7,000
Family (Individual/Family) $500/$1,500 $4,600/$9,000
Annual Pharmacy Maximum None None
Pharmacy Benefit Once the annual deductible has been met,
prescriptions are paid at 90% of the Network
Charge (as part of the medical benefit)
Once the annual deductible has been met,
prescriptions are paid at 60% of R&C (as part of
the medical benefit)
Note - Although determination of whether a provider is a Network or Non-Network provider will be made at the time the provider renders the service, the
level of benefits shall be those outlined above. For example, if in 2019, Executive seeks services from a provider who is then a Network provider, but who in
2012 is a Non-Network provider, the benefits noted under the “Network” column shall be provided. Conversely, if in 2019, Executive seeks services from a
provider who is then a Non-Network provider, but who in 2012 is a Network Provider, the benefits noted under the Non-Network column shall be provided.
Provided however, in any event, the Medicare Reimbursement Rate to be used for purposes of determining the level of the Non-Network benefit shall be the
Medicare Reimbursement Rate at the date the service is provided.