Page 57 - Cover Letter and Evaluation for Bob Workman

10/25/2017 Your Medicare Health Plan Details
Outpatient hospital coverage
In-Network: 20% per visit
Out-of-Network: 50% per visit

Doctor visits Primary:
In-Network: $10 per visit
Out-of-Network: 50% per visit

Specialist:
In-Network: $25 per visit
Out-of-Network: 50% per visit

Preventive care
In-Network: $0 copay
Out-of-Network: $0 or 50%

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Benefits Services

Hearing exam In-Network: $25
Out-of-Network: 50%

Fitting/evaluation In-Network: $0 copay
Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Hearing aids In-Network: $399-699
Out-of-Network: $399-699

There may be limits on how much the plan will provide.
Optional Supplemental Benefits

Package #1 Comprehensive dental services, Preventive dental services
Monthly Premium $34.20
Deductible N/A

Drug Plan Information

Monthly Premium N/A
Deductible N/A
Formulary Website None Available

A federal government website managed and paid for by the U.S. Centers for
Medicare &
Medicaid Services. 7500 Security Boulevard, Baltimore, MD 21244

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5216&plnid=046&sgmntid=0#plan_benefits 2/2