Page 117 - Cover Letter and Evaluation for John

10/9/2018 Your Medicare Health Plan Details
Hearing aids - inner ear Not covered

Hearing aids - outer ear Not covered

Hearing aids - over the ear Not covered

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: $0 copay
Out-of-Network: 40%

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

Contact lenses In-Network: $0 copay
Out-of-Network: $0 copay

There may be limits on how much the plan will provide.
Eyeglasses (frames and In-Network: $0 copay
lenses) Out-of-Network: $0 copay

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

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

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

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

Package #1 Comprehensive dental, Comprehensive dental services, Preventive dental, Preventive dental
services
Monthly Premium $23.00
Deductible $50.00

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5521&plnid=126&sgmntid=0#plan_benefits 4/5