•$999 copay for each Premium 
level hearing aid up to 1per ear 
per year.  
 
You must see aTruHearing 
provider to use this benefit. Call 
1-844-255-7144 to schedule an 
appointment (for TTY, dial 711). 
DENTAL SERVICES  
The cost-share indicated below is what you pay for the covered service.  
Medicare-covered dental $30 copay $30 copay 
Routine dental 
Dental services are subject to our  
standard claims review  
procedures which could include  
dental history to approved  
coverage. Dental benefits under