Page 87 - Cover Letter and Evaluation for Amy Prack

Wellness programs (e.g., fitness, Covered
nursing hotline)
Medicare Part B drugs Chemotherapy:
In-Network: 20%
Out-of-Network: 20%

Other Part B drugs:
In-Network: 20%
Out-of-Network: 20%

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Benefits Services

Hearing
Hearing exam In-Network: $50
Out-of-Network: $50

Fitting/evaluation Not covered
Hearing aids - inner ear Not covered

Hearing aids - outer ear Not covered

Hearing aids - over the ear Not covered
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)