Page 80 - Cover Letter and Evaluation for Mike Peaseley

11/17/2017 Your Medicare Health Plan Details
Benefits Services

Hearing

Hearing exam $45

Fitting/evaluation $45

There may be limits on how much the plan will provide.
Hearing aids - inner ear Not covered

Hearing aids - outer ear Not covered
Hearing aids - over the ear Not covered

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 $0 copay
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 $0 copay
lenses)
There may be limits on how much the plan will provide.
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

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H3931&plnid=126&sgmntid=0#plan_benefits 3/4