Page 70 - Cover letter and evaluation for Peter Smith

11/27/2017 Your Medicare Health Plan Details
Preventive dental
Oral exam In-Network: $0 copay
Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Cleaning In-Network: $0 copay
Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Fluoride treatment In-Network: $0 copay
Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Dental x-ray(s) In-Network: $0 copay
Out-of-Network: $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 In-Network: $0 copay
Out-of-Network: 40%

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

Contact lenses In-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
Eyeglasses (frames and In-Network: $0 copay
lenses) Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Eyeglass frames In-Network: $0 copay
Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Eyeglass lenses In-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
Upgrades Not covered

Optional Supplemental Benefits

None Available

Drug Plan Information

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=055&sgmntid=0#plan_benefits 4/5