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Welfare Summary Plan Description-Plan A
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Welfare Summary Plan Description-Plan A
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IMPORTANT CONTACT INFORMATION
IMPORTANT BENEFIT INFORMATION
SCHEDULE OF BENEFITS
ELIGIBILITY FOR BENEFITS
Your Initial Eligibility
Your Dependents' Eligibility
Qualified Medical Child Support Order (QMCSO)
Continuation of Eligibility
Termination of Your Eligibility
Termination of Dependent Eligibility
Reinstatement of Eligibility
Enrollment Procedures
Special Enrollment
Certificate of Coverage
LIFE EVENTS
Getting Married
Adding a Child
Getting Divorced or Legally Separated
Child Losing Eligibility
Taking a Family and Medical Leave of Absence
Taking a Military Leave
In the Event of Death
When You Stop Working or Retire
CONTINUATION OF HEALTH BENEFITS
Continuation of Coverage After You Die
Continuation of Coverage During Family and Medical Leave
Continuation of Coverage During Military Leave
COBRA Continuation of Coverage
COMPREHENSIVE MAJOR MEDICAL BENEFIT (EMPLOYEES AND DEPENDENTS)
Preferred Provider Organization (PPO)
Calendar Year Deductible
Common Accident
Coinsurance
Out-of-Pocket Maximum
Pre-Admission Authorization
Covered Expenses
Hospice Benefit
Extension of Benefits
WELLNESS EXPENSE BENEFIT (EMPLOYEE AND SPOUSE ONLY)
SUBSTANCE ABUSE EMPLOYEE ASSISTANCE PROGRAM (EAP) (EMPLOYEE AND DEPENDENT'S)
DENTAL BENEFITS (EMPLOYEES AND DEPENDENTS)
Delta Preferred Option USA (Point-of-Service) Program
Predetermination of Benefits
Covered Dental Services
Dental Service Limitations
Services Not Paid by the Plan
Dental Exclusions
Extension of Dental Benefits
Opt-Out of Dental Benefits
NOTICE OF BENEFIT IMPROVEMENTS - PLAN A ACTIVE
OPTICAL BENEFITS (EMPLOYEES AND DEPENDENTS)
Opt-Out of Optical Benefits
HEARING AID BENEFIT (EMPLOYEES AND DEPENDENTS)
PRESCRIPTION DRUG BENEFITS (EMPLOYEES AND DEPENDENTS)
Retail Pharmacy Network
Mail Order Prescription Drug Service
Prescription Drug Exclusions and Limitations
Prescription Drug Benefits Coordination with Medicare Part D
DEATH BENEFIT (ACTIVE EMPLOYEES ONLY)
ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS (ACTIVE EMPLOYEES ONLY)
WEEKLY ACCIDENT AND SICKNESS DISABILITY BENEFIT (ACTIVE EMPLOYEES ONLY)
Termination of Eligibility
Reinstatement of Eligibility
GENERAL EXCLUSIONS AND LIMITATIONS
HOW TO FILE A CLAIM
Filing Claims Other than Major Medical Claims
Workers' Compensation Claims Procedures
Claim Filing Period
Assignment of Benefits
Comprehensive Major Medical Benefit Claims
Weekly Accident and Sickness Disability Benefit Claims
If Your Claim is Denied
Appealing the Denial of Your Claim
Limitation on Legal Actions
Payment of Benefits
Wrongful or Erroneous Benefit Payments
COORDINATION OF BENEFITS
Determining Which Plan Pays First
Information Required for Coordination of Benefits
HOW MEDICARE AFFECTS MEDICAL BENEFITS UNDER THE PLAN
About Medicare
Coordination of Your Plan Benefits with Medicare
REIMBURSEMENT POLICIES AND PROCEDURES
Benefits to Which Reimbursement Applies
Situations Where Reimbursement Provisions May Apply
Reimbursement Procedures
Refusal to Cooperate In Reimbursement Claims
IMPORTANT INFORMATION ABOUT THE PLAN
STATEMENT OF RIGHTS UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT (ERISA)
YOUR PRIVACY RIGHTS UNDER THE PLAN
DEFINITIONS
APPENDIX A: DURABLE MEDICAL EQUIPMENT AND SUPPLIES
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