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