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Hearing Services Dental Services In -Network Out -of -Network Medicare -Covered Hearing Medicare -Covered Hearing Services Services ■ $45 copay for specialist exams to 40% of the Medicare -allowed amount diagnose and treat hearing and after $2,000 out -of -network deductible balance issues Additional Hearing Services ■ $0 copay for one routine hearing exam per year. ■ $0 copay for evaluation and fitting of hearing aids ■ $350 per ear. You pay a $0 copay for up to 2 hearing aids every year with a maximum benefit allowance of $350 per ear. Additional Hearing Services ■ Member must submit receipts for reimbursement at 50% of maximum allowed for a routine hearing exam per NOTE: Hearing aids must be purchased through our participating provider to receive in -network benefits. ■ ■ Member is responsible for any amount after the benefit allowance has been applied. Subiect to benefit maximum. Medicare -Covered Dental Services 0 • $45 copay for specialist non- routine dental care Additional Dental Services ■ $0 copay for covered preventive dental services ■ $0 copay for covered comprehensive dental services year. Member must submit receipts for reimbursement at 50% of maximum allowed for evaluation and fitting of hearing aids. Member must submit receipts for reimbursement at 50% of maximum allowed for up to 2 hearing aids every year. Subject to benefit maximum. Member is responsible for any amount after the benefit allowance has been applied. Medicare -Covered Dental Services ■ 40% of the Medicare -allowed amount after $2,000 out -of -network deductible for non -routine dental Additional Dental Services ■ Member pays up front and is reimbursed 50% of non -participating rates for covered preventive dental services. ■ Member pays up front and is reimbursed 50% of non -participating rates for covered comprehensive dental services. 8 334