per year. 
•$1000 combined maximum  
benefit coverage amount per  
year for preventive and  
comprehensive benefits. •55% of the cost for amalgam  
and/or composite filling, simple  
or surgical extraction up to 2  
per year. 
•$1000 combined maximum  
benefit coverage amount per  
year for preventive and  
comprehensive benefits. 
•Benefits received  
out-of-network are subject to  
any in-network benefit  
maximums, limitations, and/or  
exclusions. 
VISION SERVICES 
Medicare-covered vision