Page 174 - Cover Letter and Evaluation for Sue Marx

2/7/2019 Your Medicare Health Plan Details
Hearing aids In-Network: $0 copay
Out-of-Network: $0 copay

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

Oral exam In-Network: $0 copay
Out-of-Network: 30%

There may be limits on how much the plan will provide.
Cleaning In-Network: $0 copay
Out-of-Network: 30%

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

Dental x-ray(s) In-Network: $0 copay
Out-of-Network: 30%

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

Non-routine services Not covered

Diagnostic services Not covered

Restorative services In-Network: 50%
Out-of-Network: 50%

There may be limits on how much the plan will provide.
Endodontics In-Network: 50%
Out-of-Network: 50%

There may be limits on how much the plan will provide.
Periodontics In-Network: 50%
Out-of-Network: 50%

There may be limits on how much the plan will provide.
Extractions In-Network: 50%
Out-of-Network: 50%

There may be limits on how much the plan will provide.
Prosthodontics, other In-Network: 50%
oral/maxillofacial surgery, Out-of-Network: 50%
other services
There may be limits on how much the plan will provide.

Routine eye exam In-Network: $0 copay
Out-of-Network: 30%

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.

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5522&plnid=001&sgmntid=0#plan_benefits 4/6