Page 44 - Cover letter and evaluation for Peter Smith

11/27/2017 Your Medicare Health Plan Details
Benefits Services

Hearing

Hearing exam $0 copay

Fitting/evaluation Not covered

Hearing aids - inner ear $380

There may be limits on how much the plan will provide.
Hearing aids - outer ear Not covered

Hearing aids - over the ear $330

There may be limits on how much the plan will provide.
Preventive dental
Oral exam $0 copay

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

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

Dental x-ray(s) $0 copay

There may be limits on how much the plan will provide.
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 Not covered
Eyeglasses (frames and Not covered
lenses)
Eyeglass frames $0 copay

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

Optional Supplemental Benefits

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H0609&plnid=028&sgmntid=0#plan_benefits 3/4