Page 33 - APPENDICES for Janet Tuma

Extractions

In-network: 20% coinsurance
Out-of-network: 50-70% coinsurance

Limits apply

Prosthodontics, other oral/maxillofacial surgery, other services
In-network: 20% coinsurance
Out-of-network: 50-70% coinsurance

Limits apply

VISION

Routine eye exam

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

Limits apply

Contact lenses
In-network: $0 copay

Out-of-network: $0 copay

Limits apply

Eyeglasses (frames & lenses)
In-network: $0 copay
Out-of-network: $0 copay

Limits apply

Eyeglass frames (only)
In-network: $0 copay
Out-of-network: $0 copay

Limits apply

Eyeglass lenses (only)

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

Limits apply