## Vision

 ## Your vision coverage and eyewear allowance

**Your Blue Cross Medicare Advantage plan covers:****Core plan****Comfort plan****Choice plan****Complete plan****Freedom BlueSM plan**Eye exam (2 per year)  
*1 per year for Freedom Blue plan*$0$0$0$0$0Eyewear allowance  
(frames, lenses or contacts)Core Metro: $100  
Core West: $100  
Core South: $100Comfort Metro: $125  
Comfort West: $125Choice Metro: $200  
Choice West: $150  
Choice South: $125Complete Metro: $225  
Complete West: $200  
Complete South: $200Freedom: $250

**Original Medicare covers:****Core plan****Comfort plan****Choice plan****Complete plan****Freedom Blue plan**Outpatient services to diagnosis and treat eye diseases and injuries$0$0$0$0$0Annual glaucoma screening if you are at high-risk:  
- You have diabetes  
- You have a family history of glaucoma  
- You’re African American and age 50 or older   
- You’re Hispanic and age 65 or older$0$0$0$0$0Eyewear after cataract surgery$0$0$0$0$0Diabetic retinopathy exam$0$0$0$0$0For complete details, please visit our [Medicare documents page](https://www.bluecrossmn.com/forms/search?keywords=&audience%5B1436%5D=1436&plan_type%5B1051%5D=1051&plan%5B921%5D=921&plan%5B1541%5D=1541&plan%5B1581%5D=1581&plan%5B926%5D=926&doc_type%5B1141%5D=1141&field_dam_metadata_language=All&sort_by=changed) and select the Evidence of Coverage (EOC) document for your plan. Vision care information can be found in Chapter 4 of the document.





 

 

 

 

 

## Dental

 ## Your dental benefits

All Individual Blue Cross and Blue Shield of Minnesota Medicare Advantage plans cover preventive dental care at no extra cost.\*

**Your Blue Cross plan covers:****Core plan****Comfort plan****Choice plan****Complete plan****Freedom Blue plan****Preventive**  
Oral exams (2)$10 copay$0$0$0$0**Preventive**  
Cleanings (2), fluoride treatments (2), X-rays (1), periodontal cleanings (2)$0$0$0$0$0**Restorative**  
FillingsNot covered30% coinsurance Metro;  
50% coinsurance West30% coinsurance30% coinsurance20% coinsurance**Comprehensive**  
Extractions, endodontics, periodontics (treatment of periodontitis and gingivitis), special restorative, prosthetics, crowns, oral surgical procedures  
*Note: Cosmetic procedures and implants are not covered*.Not covered60% coinsurance Metro;  
70% coinsurance West50% coinsurance50% coinsurance20% coinsurance**Maximum plan benefit\***$1,000$1,750 Metro;  
$1,250 West$2,000 Metro and South;  
$1,500 West$2,000$2,500\*The maximum plan benefit is the maximum amount the plan will pay for all in-network and out-of-network covered dental services.

\*For dental services performed by an out-of-network dentist, you will be responsible for paying the difference between the dentist's fees and Blue Cross Medicare Advantage out-of-network provider reimbursement rates, even for services listed as $0 copay.

\*For complete details, including the cost sharing of covered services, exceptions and limitations, please visit our [Medicare documents page](https://www.bluecrossmn.com/forms/search?keywords=&audience%5B1436%5D=1436&plan_type%5B1051%5D=1051&plan%5B921%5D=921&plan%5B1541%5D=1541&plan%5B1581%5D=1581&plan%5B926%5D=926&doc_type%5B1141%5D=1141&field_dam_metadata_language=All&sort_by=changed) and select the Evidence of Coverage (EOC) document for your plan. Dental care information can be found in Chapter 4 of the document.

Original Medicare covers:Core planComfort planChoice planComplete planFreedom Blue planHospital performed dental services covered under Part A  
*Generally due to an emergency situation. Fees very based on your plan and in-network or out-of-network facility.*$50$30$30$20$30In most cases, Original Medicare doesn't cover dental services like routine cleanings, fillings, tooth extractions (removals), or items like dentures and implants.  
[View what dental services Original Medicare may cover](https://www.medicare.gov/coverage/dental-services)





 

 

 

 

 

## Hearing

 ## Your hearing and hearing aid benefits

Your plan covers up to two hearing aids per year.

Your Blue cross plan covers:Core planComfort planChoice planComplete planFreedom Blue planHearing screening (1 per year)  
*Performed by your physician, an audiologist or other qualified provider*$0$0$0$0$0Hearing aid screening (1 per year)  
*Must be performed by your TruHearing provider*$0$0$0$0$0Hearing aid (up to 2 aids per year)  
*Rechargeable battery option is available on select styles for no additional cost.*$699 copay per aid for Advanced Aid or $999 copay per aid for Premium Aid from TruHearing$599 copay per aid for Advanced Aid or $899 copay per aid for Premium Aid from TruHearing$599 copay per aid for Advanced Aid or $899 copay per aid for Premium Aid from TruHearing$499 copay per aid for Advanced Aid or $799 copay per aid for Premium Aid from TruHearing$599 copay per aid for Advanced Aid or $899 copay per aid for Premium Aid from TruHearing

[Visit TruHearing for more information](https://www.truhearing.com/bcbsmnma)

Original Medicare covers:Core planComfort planChoice planComplete planFreedom Blue planDiagnostic hearing and balance exam  
*Doctor ordered exam to see if you need medical treatment.*  
*Your cost share may vary based on your plan and in-network or out-of-network provider/facility.*$0 copay$0 copay$0 copay$0 copay$0 copay



 

 

 

 

 

TruHearing® is a registered trademark of TruHearing, Inc., an independent company who works with health plans to offer low out-of-pocket costs on hearing aids.

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