Page 87 - Cover Letter & Evaluation for Michael Novotny
P. 87
6/9/2018 Your Medicare Health Plan Details
Hearing exam $5
Fitting/evaluation Not covered
Hearing aids - inner ear $380
There may be limits on how much the plan will provide.
Hearing aids - outer ear Not covered
Hearing aids - over the ear $330
There may be limits on how much the plan will provide.
Oral exam Not covered
Cleaning Not covered
Fluoride treatment Not covered
Dental x-ray(s) Not covered
Non-routine services Not covered
Diagnostic services Not covered
Restorative services Not covered
Endodontics Not covered
Periodontics Not covered
Extractions Not covered
Prosthodontics, other Not covered
oral/maxillofacial surgery,
other services
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.
Eyeglasses (frames and Not covered
lenses)
Eyeglass frames $0 copay
There may be limits on how much the plan will provide.
Eyeglass lenses $0 copay
There may be limits on how much the plan will provide.
Upgrades Not covered
Optional Supplemental Benefits
Package #1 Comprehensive dental services, Preventive dental services
Monthly Premium $12.50
Deductible N/A
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H0543&plnid=004&sgmntid=0 3/4
