Page 81 - APPENDICES for Fred Falten

Dialysis

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

Limits apply

Diabetes supplies
In-network: $0 copay or 10-20% coinsurance per item
Out-of-network: 20-30% coinsurance per item

Limits apply

Extra bene ts & costs

HEARING

Hearing exam
In-network: $45 copay
Out-of-network: $65 copay

Limits apply

Fitting/evaluation
In-network: $0 copay
Out-of-network: $0 copay

Limits apply

Hearing aids - All types

In-network: $699-999 copay
Out-of-network: $699-999 copay

Limits apply

PREVENTIVE DENTAL

Oral exam
Not covered