Page 61 - Cover Letter and Evaluation for Barbara Lesswing

11/18/2017 Your Medicare Health Plan Comparison
Hearing Independent Health Encompass 65 Independent Health Encompass 65
(HMO) Basic (HMO)
Hearing exam $25 $25
Fitting/evaluation Not covered Not covered
Hearing aids $699-999 $699-999
Preventive Dental Independent Health Encompass 65 Independent Health Encompass 65
(HMO) Basic (HMO)
Office visit $20.00 $20.00
Oral exam Covered under office visit Covered under office visit
There may be limits on how much the plan There may be limits on how much the plan
will provide. will provide.
Cleaning Covered under office visit Covered under office visit
There may be limits on how much the plan There may be limits on how much the plan
will provide. will provide.
Fluoride treatment Not covered Not covered
Dental x-ray(s) Covered under office visit Covered under office visit
There may be limits on how much the plan There may be limits on how much the plan
will provide. will provide.
Comprehensive Dental Independent Health Encompass 65 Independent Health Encompass 65
(HMO) Basic (HMO)
Non-routine services Not covered Not covered
Diagnostic services Not covered Not covered
Restorative services Not covered Not covered
Endodontics Not covered Not covered
Periodontics Not covered Not covered
Extractions Not covered Not covered
Prosthodontics, other oral/maxillofacial Not covered Not covered
surgery, other services
Vision Independent Health Encompass 65 Independent Health Encompass 65
(HMO) Basic (HMO)
Routine eye exam $0 copay $0 copay
There may be limits on how much the plan There may be limits on how much the plan
will provide. will provide.
Other Not covered Not covered
Contact lenses $0 copay $0 copay
There may be limits on how much the plan There may be limits on how much the plan
will provide. will provide.
Eyeglasses (frames and lenses) $0 copay $0 copay
There may be limits on how much the plan There may be limits on how much the plan
will provide. will provide.
Eyeglass frames Not covered Not covered
Eyeglass lenses Not covered Not covered
Upgrades Not covered Not covered
Optional Supplemental Benefits

Independent Health Encompass 65 Independent Health Encompass 65
(HMO) Basic (HMO)
Not Available Not Available
Drug Plan Information

Outpatient Prescription Independent Health Encompass 65 Independent Health Encompass 65
Drugs (HMO) Basic (HMO)

Monthly Premium N/A $86.30
Deductible N/A $0
Formulary Website Not Available View formulary website 
Initial Coverage Phase Independent Health Encompass 65 Independent Health Encompass 65
(HMO) Basic (HMO) 1

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