Page 62 - Cover letter and evaluation for Michele Buros

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

Wellness programs (e.g., fitness, Covered
nursing hotline)
Medicare Part B drugs Chemotherapy:
In-Network: 20%
Out-of-Network: 20%

Other Part B drugs:
In-Network: $0 or 20%
Out-of-Network: 20%

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Benefits Services

Hearing
Hearing exam In-Network: 20%
Out-of-Network: 20%

Fitting/evaluation Not covered

Hearing aids - inner ear Not covered

Hearing aids - outer ear Not covered

Hearing aids - over the ear Not covered
Preventive dental
Oral exam In-Network: $0 copay
Out-of-Network: 50%
There may be limits on how much the plan will provide.
Cleaning In-Network: $0 copay
Out-of-Network: 50%

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

Dental x-ray(s) In-Network: $0 copay
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 In-Network: $0 copay
Out-of-Network: 50%

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

Periodontics Not covered

Extractions Not covered

Prosthodontics, other Not covered
oral/maxillofacial surgery,
other services
Vision

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