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 $37.10 
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: 
Plan covers up to  $2,000 allowance every year for non-Medicare covered preventive and comprehensive