Page 30 - Cover letter and evaluation for Peter Smith

11/27/2017 Your Medicare Health Plan Details
Medicare Part B drugs Chemotherapy: 20%

Other Part B drugs: 0-20%

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Benefits Services

Hearing
Hearing exam $0 copay
Fitting/evaluation $0 copay

There may be limits on how much the plan will provide.
Hearing aids $0 copay

There may be limits on how much the plan will provide.
Preventive dental
Oral exam Not covered

Cleaning Not covered
Fluoride treatment Not covered

Dental x-ray(s) Not covered

Comprehensive dental
Non-routine services Not covered

Diagnostic services Not covered

Restorative services Not covered
Endodontics Not covered

Periodontics Not covered

Extractions Not covered
Prosthodontics, other Not covered
oral/maxillofacial surgery,
other services
Vision
Routine eye exam $0 copay

There may be limits on how much the plan will provide.
Other Not covered

Contact lenses $25

There may be limits on how much the plan will provide.
Eyeglasses (frames and Not covered
lenses)
Eyeglass frames $25

There may be limits on how much the plan will provide.
Eyeglass lenses $0 copay

There may be limits on how much the plan will provide.
Upgrades Not covered

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H4346&plnid=001&sgmntid=0 3/5