Page 52 - APPENDICES for Stephen Spero
P. 52
Extractions
Not covered
Prosthodontics, other oral/maxillofacial surgery, other services
Not covered
VISION
Routine eye exam
$0 copay
Limits apply
Contact lenses
$0 copay
Limits apply
Eyeglasses (frames & lenses)
$0 copay
Limits apply
Eyeglass frames (only)
$0 copay
Limits apply
Eyeglass lenses (only)
$0 copay
Limits apply
Upgrades
Not covered
MEDICALLY-APPROVED NON-OPIOID PAIN MANAGEMENT SERVICES
Chiropractic services
Not covered
