Page 55 - APPENDICES for Neill McLauchlin

In-network: 20% coinsurance
Out-of-network: 30% coinsurance

Limits apply

Diabetes supplies
In-network: 0-20% coinsurance per item
Out-of-network: 30% coinsurance per item

Limits apply

Extra bene ts & costs

HEARING

Hearing exam
In-network: $0-25 copay
Out-of-network: $55 copay

Fitting/evaluation

In-network: $0 copay
Out-of-network: 30% coinsurance

Limits apply

Hearing aids - Inner ear
In-network: $0 copay
Out-of-network: $0 copay

Limits apply

Hearing aids - Outer ear
In-network: $0 copay
Out-of-network: $0 copay

Limits apply

Hearing aids - Over the ear
In-network: $0 copay
Out-of-network: $0 copay

Limits apply