Page 76 - Cover Letter & Evaluation for Michael Novotny

6/9/2018 Your Medicare Health Plan Details

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Benefits Services

Hearing exam $0 copay

Fitting/evaluation $0 copay

There may be limits on how much the plan will provide.
Hearing aids - inner ear Not covered

Hearing aids - outer ear Not covered

Hearing aids - over the ear Not covered

Oral exam $0 copay

There may be limits on how much the plan will provide.
Cleaning $0 copay

There may be limits on how much the plan will provide.
Fluoride treatment $0-20

There may be limits on how much the plan will provide.
Dental x-ray(s) $0-30

There may be limits on how much the plan will provide.

Non-routine services $0 copay

There may be limits on how much the plan will provide.
Diagnostic services $0-30

There may be limits on how much the plan will provide.
Restorative services $20-350

There may be limits on how much the plan will provide.
Endodontics $15-375

There may be limits on how much the plan will provide.
Periodontics $15-375

There may be limits on how much the plan will provide.
Extractions $25-140

There may be limits on how much the plan will provide.
Prosthodontics, other $20-425
oral/maxillofacial surgery,
other services There may be limits on how much the plan will provide.

Routine eye exam $0 copay

There may be limits on how much the plan will provide.
Other Not covered

Contact lenses $0 copay

There may be limits on how much the plan will provide.

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H3815&plnid=001&sgmntid=0#plan_benefits 3/5