Outpatient X-rays $0 to  $90 copay $0 to  $90 copay 
Radiation therapy $30 copay or  20% of the cost $30 copay or  20% of the cost 
HEARING SERVICES 
Medicare-covered hearing $30 copay $30 copay You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs 
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please