per ear per year. 
•$1299 copayment for each Premium Technology hearing aid up to 1  
per ear per year. 
•Note: Includes 1year warranty and 1month battery supply. 
Dental Medicare-covered dental services:  $25 copay  
Routine dental:  
The cost-share indicated below is what you pay for the covered service. 
In-Network: 
DEN613 
•0% coinsurance for scaling and root planing (deep cleaning) up to 1  
per quadrant every 3years. 
•0% coinsurance for comprehensive oral evaluation or periodontal