Page 75 - Cover letter and evaluation for Michele Buros

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Oral exam In-Network: $0 copay
Out-of-Network: $0 copay

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

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

There may be limits on how much the plan will provide.
Dental x-ray(s) In-Network: $0 copay
Out-of-Network: $0 copay

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: 20%

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

Optional Supplemental Benefits

None Available

Drug Plan Information

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