Page 78 - Cover Letter and Evaluation for Debbie Workman

12/13/2017 Your Medicare Health Plan Details
Fitting/evaluation Not covered
Hearing aids - inner ear $380

There may be limits on how much the plan will provide.
Hearing aids - outer ear Not covered

Hearing aids - over the ear $330

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 $20

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 Not covered
lenses)
Eyeglass frames $0 copay

There may be limits on how much the plan will provide.
Eyeglass lenses $0 copay

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

Optional Supplemental Benefits

None Available

Drug Plan Information
Outpatient Prescription Drugs

Monthly Premium $17.00
Deductible $180
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H1286&plnid=002&sgmntid=0 3/4