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City of Lakewood : Plan 1 coverage Pnr od: 0110112017 - M3112017 <br />Summaryof Benefice end Coverage: YAni Thk Ptan Cor¢rtdwhalh Casls Covengfx. SrPr,Fnrdyl Plan Type: FPO <br />City of Lakewood: Plan 1 Coverage Period: 0110 1;2o17 -IW11301T <br />Bpmmaryof Benefdeand Coverage: YA91this Plan Covers dNhafitCwts CoveraV for. Sirde w F,,* l Plan Type: PM <br />Excluded Service. d Other Covered Service.: <br />Servires Yow Plan floes NOTCover RM1iz knhammplek Gsl. Chezk yourpolle/wpian dowmerdfmolher asAeded•vrtee=.) <br />- P.ayanGne <br />Hea-ig Ake RauCw EYe GarelAda9) <br />- Cnr k3umery <br />MiAII Tn,,.t Rwlne Font Care <br />- Omil drxio (Chb) <br />Lo Temr Can Wei hl Lov Fngremz <br />- O WCae(AddG <br />- Naacrerg rycrewfimhas.gx.Wile Me <br />G.. <br />US <br />dherCwered3erden (This isnlu mmplele llsL Checkyourpolicy or plan doaumanl foratheraevered eervixs and yomwshtorlhese eeMus.( <br />Barhide Sw9erf Ctuapraa`cCare PdvaraekayfMmrg <br />Your Right. to Continue Coverage: <br />Bym Y_ arrerge�.dniheplaPdR"a', dryimdxg u�nttzawmsAnxa, Fadaa'aM else h-nmaY povifepogt 5utaprocyau Wkeep heaU orveme. Any <br />suirn3M1bmaY to rovedi.te to onr... prey vreyw:opn,,h. ypAxkHi amybaignSwnllykgher ThanthepremvmyoupayxTie oneredwidx Meflan. <br />9drer Grth'sroontrurrgF.h b onrwemremge nay ales epAty. <br />Fm Roe^'cGemalw cnyawryhtaWxnLmre manage, dadaxtlnp�at8W.51025B3. Ywu yalwmn [rywsb9ms sedeparM to eUS.1Y.garinsMal <br />Lahr, Errp`ccyee BereBls Seo.aity Admm4afan a186d dG4 3212 or w1.w dMgm'shea, w be U S. OeparhraM of Nealit and Heamn Scrr�s al8]I2fi]2323 %6 t k5 w <br />wa'.v.oiamiagaa. <br />30 <br />