Page 56 - Cover letter and evaluation for Peter Smith
P. 56
11/27/2017 Your Medicare Health Plan Details
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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 $0 copay
lenses)
There may be limits on how much the plan will provide.
Eyeglass frames Not covered
Eyeglass lenses Not covered
Upgrades Not covered
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H2931&plnid=002&sgmntid=0#plan_benefits 3/5
