Page 79 - Cover Letter & Evaluation for Isaac Kapon

10/5/2017 Your Medicare Health Plan Details
Outpatient hospital coverage
In-Network: 20% per visit
Out-of-Network: 40% per visit

Doctor visits Primary:
In-Network: $5 per visit
Out-of-Network: 40% per visit

Specialist:
In-Network: $45 per visit
Out-of-Network: 40% per visit

Preventive care
In-Network: $0 copay
Out-of-Network: $0 or 40%

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Benefits Services

Hearing exam In-Network: $45
Out-of-Network: 40%

Fitting/evaluation In-Network: $0 copay
Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Hearing aids In-Network: $699-999
Out-of-Network: $699-999

There may be limits on how much the plan will provide.
Optional Supplemental Benefits

Package #1 Comprehensive dental services, Preventive dental services
Monthly Premium $27.40
Deductible N/A

Drug Plan Information

Monthly Premium $0.00
Deductible $365
Formulary Website View formulary website 

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