Page 109 - Cover Letter and Evaluation for Paul Dorroh

Your Medicare Health Plan Details https://www.medicare.gov/find-a-plan/results/planresults/plan-details.as...

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.

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

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

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

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