Welfare Summary Plan Description-Plan A

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