Page 54 - Cover Letter and Evaluation for Amy Prack
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Benefits Services
Hearing
Hearing exam $45
Fitting/evaluation $0 copay
There may be limits on how much the plan will provide.
Hearing aids $699-999
There may be limits on how much the plan will provide.
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 Not covered
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
Package #1 Comprehensive dental, Comprehensive dental services, Preventive dental, Preventive dental services
Monthly Premium $19.90
Deductible N/A
