Page 91 - Appendices to Jane Miller's evaluation

Limits apply

Dialysis
In-network: 20% coinsurance
Out-of-network: 50% coinsurance

Limits apply

Diabetes supplies
In-network: 0-20% coinsurance per item

Out-of-network: 0-20% coinsurance per item

Limits apply

Extra bene ts & costs

HEARING

Hearing exam
In-network: $45 copay

Out-of-network: 40% coinsurance

Fitting/evaluation
In-network: $0 copay
Out-of-network: 40% coinsurance

Limits apply

Hearing aids - All types
In-network: $0 copay
Out-of-network: $0 copay

Limits apply

PREVENTIVE DENTAL

Oral exam
In-network: $0 copay
Out-of-network: $0 copay