Page 35 - Cover letter and evaluation for Michele Buros

Your Medicare Health Plan Details https://www.medicare.gov/find-a-plan/results/planresults/plan-details.as...

Fitting/evaluation Not covered
Hearing aids In-Network: $699-999
Out-of-Network: $699-999
There may be limits on how much the plan will provide.
Preventive dental
Office visit In-Network: $30.00
Out-of-Network: 50%

Oral exam Covered under office visit

There may be limits on how much the plan will provide.
Cleaning Covered under office visit

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

Dental x-ray(s) In-Network: $25
Out-of-Network: 50%

There may be limits on how much the plan will provide.
Comprehensive dental
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
Vision
Routine eye exam In-Network: $0 copay
Out-of-Network: $50

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

Contact lenses In-Network: $0 copay
Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Eyeglasses (frames and Not covered
lenses)
Eyeglass frames In-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
Eyeglass lenses In-Network: $0 copay
Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Upgrades In-Network: $0 copay
Out-of-Network: $0 copay

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

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