Page 85 - Cover Letter & Evaluation for Isaac Kapon
P. 85
10/5/2017 Your Medicare Health Plan Details
Outpatient hospital coverage
In-Network: $45-275 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: 0-40%
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Benefits Services
Hearing exam In-Network: $45
Out-of-Network: 40%
Fitting/evaluation In-Network: $45
Out-of-Network: 40%
There may be limits on how much the plan will provide.
Hearing aids - inner ear Not covered
Hearing aids - outer ear Not covered
Hearing aids - over the ear Not covered
Optional Supplemental Benefits
None Available
Drug Plan Information
Monthly Premium $46.00
Deductible $75
Formulary Website View formulary website
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