comprehensive benefits. 
•Benefits received  
out-of-network are subject to  
any in-network benefit  
maximums, limitations, and/or  
exclusions. 
VISION SERVICES 
Medicare-covered vision 
services $40 copay 30% of the cost 
Medicare-covered diabetic eye 
exam $0 copay 30% of the cost 
Medicare-covered glaucoma 
screening $0 copay 30% of the cost 
Medicare-covered eyewear