Page 155 - Cover Letter and Evaluation for Gary Janke

10/8/2018 Your Medicare Health Plan Details
Hearing aids In-Network: $599-899
Out-of-Network: $599-899

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

Oral exam In-Network: $0 copay
Out-of-Network: $0 copay

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

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

Dental x-ray(s) In-Network: $0 copay
Out-of-Network: $0 copay

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

Non-routine services In-Network: $0 copay
Out-of-Network: $0 copay

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

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

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

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

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

There may be limits on how much the plan will provide.
Prosthodontics, other In-Network: $0 copay
oral/maxillofacial surgery, Out-of-Network: $0 copay
other services
There may be limits on how much the plan will provide.

Routine eye exam In-Network: $40
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 Not covered

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