Page 72 - Cover Letter and Evaluation for Amy Prack

Hearing exam $5
Fitting/evaluation Not covered

Hearing aids $300-2,025
There may be limits on how much the plan will provide.
Preventive dental
Oral exam $0 copay
There may be limits on how much the plan will provide.
Cleaning $0 copay
There may be limits on how much the plan will provide.
Fluoride treatment $0 copay
There may be limits on how much the plan will provide.
Dental x-ray(s) $0 copay
There may be limits on how much the plan will provide.
Comprehensive dental
Non-routine services Not covered
Diagnostic services 0-50%

There may be limits on how much the plan will provide.
Restorative services 20-50%
There may be limits on how much the plan will provide.
Endodontics 50%
There may be limits on how much the plan will provide.
Periodontics 50%
There may be limits on how much the plan will provide.
Extractions 50%

There may be limits on how much the plan will provide.
Prosthodontics, other 0-50%
oral/maxillofacial surgery,
other services There may be limits on how much the plan will provide.
Vision
Routine eye exam $0 copay

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

Contact lenses $0 copay
There may be limits on how much the plan will provide.
Eyeglasses (frames and $0 copay
lenses)
There may be limits on how much the plan will provide.
Eyeglass frames Not covered

Eyeglass lenses Not covered
Upgrades Not covered

Optional Supplemental Benefits

None Available