Page 69 - Cover letter and evaluation for Thomas Barr
P. 69
10/14/2017 Your Medicare Health Plan Details
Outpatient hospital coverage
In-Network: $395 per visit
Out-of-Network: 50% per visit
Doctor visits Primary:
In-Network: $10 per visit
Out-of-Network: 30% per visit
Specialist:
In-Network: $50 per visit
Out-of-Network: 30% per visit
Preventive care
In-Network: $0 copay
Out-of-Network: 50%
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Benefits Services
Hearing exam In-Network: $50
Out-of-Network: 50%
Fitting/evaluation Not covered
Hearing aids In-Network: $699-999
Out-of-Network: $699-999
There may be limits on how much the plan will provide.
Optional Supplemental Benefits
Package #1 Comprehensive dental services
Monthly Premium $28.00
Deductible N/A
Drug Plan Information
Monthly Premium $41.30
Deductible $0
Formulary Website View formulary website
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