Page 64 - Cover Letter and Evaluation for Debbie Workman
P. 64
12/13/2017 Your Medicare Health Plan Details
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Benefits Services
Hearing
Hearing exam $50
Fitting/evaluation $0 copay
There may be limits on how much the plan will provide.
Hearing aids $499-799
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 $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
Package #1 Comprehensive dental services, Preventive dental services
Monthly Premium $37.80
Deductible $50.00
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5619&plnid=060&sgmntid=0#plan_benefits 3/4
