Page 68 - Evaluation for 2018

1/3/2018 Your Medicare Health Plan Details
Hearing aids - inner ear $380
There may be limits on how much the plan will provide.
Hearing aids - outer ear Not covered
Hearing aids - over the ear $330

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

Oral exam Not covered
Cleaning Not covered

Fluoride treatment Not covered

Dental x-ray(s) Not covered

Comprehensive dental
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
Vision
Routine eye exam $20

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

Contact lenses $0 copay

There may be limits on how much the plan will provide.
Eyeglasses (frames and Not covered
lenses)
Eyeglass frames $0 copay
There may be limits on how much the plan will provide.
Eyeglass lenses $0 copay
There may be limits on how much the plan will provide.
Upgrades Not covered

Optional Supplemental Benefits

None Available

Drug Plan Information

Outpatient Prescription Drugs
Monthly Premium $17.00
Deductible $180
Formulary Website View formulary website 

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H1286&plnid=002&sgmntid=0 3/4