Page 188 - Cover Letter and Evaluation for Sue Marx

2/7/2019 Your Medicare Health Plan Details
Benefits Services

Hearing exam $35

Fitting/evaluation $0 copay

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

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

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.

Non-routine services $0 copay

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

Restorative services $0 copay

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

Periodontics Not covered

Extractions $0 copay

There may be limits on how much the plan will provide.
Prosthodontics, other Not covered
oral/maxillofacial surgery,
other services

Routine eye exam $0 copay

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

Contact lenses $0 copay

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

Optional Supplemental Benefits

None Available
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H3907&plnid=046&sgmntid=0#plan_benefits 3/4