Welfare Summary Plan Description - Plan for Retired Members

WELFARE SUMMARY PLAN DESCRIPTION - RETIRED MEMBERS

IMPORTANT CONTACT INFORMATION

IMPORTANT BENEFIT INFORMATION

SCHEDULE OF BENEFITS

• Schedule of Benefits for Non-Medicare Eligible Retirees
• Schedule of Benefits for Medicare Eligible Retirees

NON-MEDICARE ELIGIBILE RETIREES' ELIGIBILITY FOR BENEFITS

• Eligibility Requirements for Non-Medicare Eligible Retirees
• Continuation of Eligibility for Non-Medicare Eligible Retirees
• Eligibility for Dependents of Non-Medicare Eligible Retirees
• Deferring a Spouse's Coverage for Non-Medicare Eligible Retirees
• Termination of Eligibility for Non-Medicare Eligible Retirees and Eligible Dependents
• Your Dependents' Eligibility
• Qualified Medical Child Support Order (QMCSO)
• Special Enrollment

MEDICARE ELIGIBLE RETIREES' ELIGIBILITY FOR BENEFITS

• Eligibility Requirements for Medicare Eligible Retirees
• Continuing Eligibility for Medicare Eligible Retirees
• Eligibility of Dependents of Medicare Eligible Retirees
• Termination of Eligibility for Medicare Eligible Retirees and Dependents
• Special Enrollment

ENROLLMENT PROCEDURES

CONTINUATION OF HEALTH BENEFITS

• Continuation of Coverage After You Die
• Special Rules for Continuation of Coverage under the Retiree Plan for Dependents of Deceased Active Employees
• Continuation of Coverage for Dependents of Deceased Retirees
• COBRA Continuation Coverage

COMPREHENSIVE MAJOR MEDICAL BENEFIT (FOR NON-MEDICARE ELIGIBLE RETIREES ONLY)

• Preferred Provider Organization (PPO)
• Calendar Year Deductible
• Common Accident
• Coinsurance
• Out-of-Pocket Maximum
• Pre-Admission Authorization
• Covered Expenses
• Hospice Benefit

WELLNESS EXPENSE BENEFIT (RETIREE AND SPOUSE ONLY)

DENTAL BENEFITS (RETIREES 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

OPTICAL BENEFITS (RETIREES AND DEPENDENTS)

• Opt-Out of Optical Benefits

HEARING AID BENEFIT (RETIREES AND DEPENDENTS)

PRESCRIPTION DRUG BENEFITS (RETIREES 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 (RETIREES ONLY)

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS (RETIREES ONLY)

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
• 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