Page 49 - Cover letter and evaluation for Michele Buros

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

Preventive dental
Oral exam Not covered

Cleaning Not covered
Fluoride treatment Not covered

Dental x-ray(s) Not covered

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: 40%
There may be limits on how much the plan will provide.
Other Not covered
Contact lenses Not covered

Eyeglasses (frames and Not covered
lenses)
Eyeglass frames Not covered
Eyeglass lenses Not covered

Upgrades Not covered

Optional Supplemental Benefits

None Available

Drug Plan Information

Outpatient Prescription Drugs
Monthly Premium $22.00
Deductible $0
Formulary Website View formulary website
Initial Coverage Phase
Tier 1 Preferred Generic
1-Month: $0.00 copay
3-Month: $0.00 copay
All: Not Available

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