Page 66 - APPENDICES for Janet Tuma

50-70% coinsurance
Limits apply

Endodontics

Not covered

Periodontics
Not covered

Extractions
50% coinsurance

Limits apply

Prosthodontics, other oral/maxillofacial surgery, other services
70% coinsurance

Limits apply

VISION

Routine eye exam
$0 copay

Limits apply

Contact lenses

$0 copay

Limits apply

Eyeglasses (frames & lenses)
$0 copay

Limits apply

Eyeglass frames (only)

Not covered

Eyeglass lenses (only)
Not covered