Page 81 - Cover Letter & Evaluation for Patricia Letizia

10/11/2018 Your Medicare Health Plan Details
Wellness programs (e.g., fitness, Covered
nursing hotline)
Medicare Part B drugs Chemotherapy:
In-Network: 20%
Out-of-Network: 25%

Other Part B drugs:
In-Network: 20%
Out-of-Network: 25%

View Less

Benefits Services

Hearing exam In-Network: $15
Out-of-Network: $25

Fitting/evaluation Not covered

Hearing aids In-Network: $1,220-1,985
Out-of-Network: $1,220-1,985

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

Oral exam Not covered

Cleaning Not covered

Fluoride treatment Not covered

Dental x-ray(s) Not covered

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: $10
Out-of-Network: 100%

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

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5215&plnid=009&sgmntid=0#plan_benefits 4/6