Page 65 - APPENDICES for Fred Falten

In-network: 20% coinsurance
Out-of-network: 20% coinsurance

Limits apply

Diabetes supplies
In-network: $0 copay
Out-of-network: 20% coinsurance per item

Extra bene ts & costs

HEARING

Hearing exam

In-network: $40 copay
Out-of-network: $55 copay

Limits apply

Fitting/evaluation

In-network: $0 copay
Limits apply

Hearing aids - All types
In-network: $495-1,095 copay

Limits apply

PREVENTIVE DENTAL

Oral exam
Covered under o ce visit

Limits apply

Cleaning

Covered under o ce visit

Limits apply