Page 31 - APPENDICES for Janet Tuma

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: $35 copay
Out-of-network: $50 copay

Fitting/evaluation

In-network: $0 copay
Out-of-network: $50 copay

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: 30% coinsurance

Limits apply

Cleaning