choose to add to your Medicare Advantage plan. However, you will have to pay an extra monthly premium 
for it. 
In this plan, you may receive your care from either an in-network or out-of-network dentist. If you use an 
out-of-network dentist, your share of the cost may be higher.  
Monthly Cost 
Monthly Premium $33.90 
Coverage Information 
Maximum plan benefit 
(combined in and out-of-network) $2,000 per calendar year 
Deductible $0 per calendar year 
You may receive the following dental services: