Page 47 - Cover Letter & Evaluation for Patricia Letizia

10/12/2018 Your Medicare Health Plan Details
Hearing exam In-Network: $40
Out-of-Network: 50%

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: $599-899
Out-of-Network: $599-899

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

Oral exam In-Network: $0 copay
Out-of-Network: 50%

There may be limits on how much the plan will provide.
Cleaning In-Network: $0 copay
Out-of-Network: 50%

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

Dental x-ray(s) In-Network: $0 copay
Out-of-Network: 50%

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

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

Routine eye exam In-Network: $0 copay
Out-of-Network: $0 copay

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

Contact lenses Not covered

Eyeglasses (frames and Not covered
lenses)
Eyeglass frames Not covered

Eyeglass lenses Not covered

Upgrades Not covered

Optional Supplemental Benefits

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5525&plnid=004&sgmntid=0#plan_benefits 4/5