Page 77 - Appendices to Jane Miller's evaluation

Prosthetics (like braces, arti cial limbs)

In-network: 20% coinsurance per item
Out-of-network: 50% coinsurance per item

Limits apply

Dialysis
In-network: 20% coinsurance
Out-of-network: 20% coinsurance

Limits apply

Diabetes supplies
In-network: $0 copay per item
Out-of-network: 40% coinsurance per item

Limits apply

Extra bene ts & costs

HEARING

Hearing exam
In-network: $0 copay
Out-of-network: $70 copay

Limits apply

Fitting/evaluation

Not covered

Hearing aids - All types
In-network: $375-2,075 copay
Out-of-network: $375 copay

Limits apply

PREVENTIVE DENTAL