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City of Lakewood : Plan 1 Coverage Period: 0110112017 - ID3112017 <br />Summary of Benefits and Coverage: Ma Rns Plan Cavers&vlhaBtCoaa Co..,. toc Sima or Feely l Plan Type: PPO <br />Ouesuona: Ca9800.54O2583ar Oota, at Ivac WtialmMSSC. Yv 4of8 <br />Ifyou areNt ekar shoal any of Na mldedned lama uad n ItsSan, are On, Gbsssry. Yav ran vaw ne GbssaN rat SYSst <br />at MWMutual av JSBC m cog 800.5102503 In iaquaata wpy ncri.a.u.aacP,r_af.--., <br />City of Lakewood : Plan 1 Coverage Period: (1110+1201y-1213112017 <br />Summary of Benefits and Coverage: Whak This Plan Covers&whatH Costa Coverage for. Sbgk or Famit,, l Wan Type: PM <br />Exoludetl Servlces & Other Covered $.mines: <br />Servleen Your Plan (roes NOT Cover fPubs Isn't a complain list Check your pplicy or plan Sentiment for ther excluded aervlcea.) <br />• ""eerie <br />Hernu Ads Rwfiae Eye Care Phdel0 <br />• Cevran Surgery <br />InleriATu,nvol RauGno Fool Care <br />• pmld dmdupf vd) <br />Lm Taimcve 4Ye5ML.PmOmnvs <br />penal Coe PaIA) <br />Nanemeyenry wre when traveling naleidoM <br />ofasee <br />u S <br />Omer Covered Servkm Qhls knYa completeikt CFwkyourpolicyarplan denument lorolherroveredservkes andyourwab forlM1eaa aervkae.) <br />Bauaac Srgery gnmpedic Cme Pdvoteeuty Nurirg <br />Your Rights to Continue Coverage: <br />Iryoulose aovera0e oMer lM1eplan,then. depenA�gupon lhecvamalaukes, Fadealead Sate laxsmayporide poleNom aalandava ra bkeep M1ealihrovttege. My <br />such agha may eelmf etl a tlma5an antl tw® rega�e you to pnY a ptem,ym. xfiiclu maY tm sgnukandy hyher 0on the prenrum Yoa pay xab mrered cruder ae plan. <br />Olho fimilationsan yourngh4alo wngnuewvoage may ekwapply <br />For. infor nabon on yo s,ents to wnhnuemvsage, ovrfo ran. .1000.vW2583. You meyalseamtaalyoursala nsrrence depedmen4 ma uS oepadmeatd <br />Lebor,Emgoyee BeneNS CauMy Admin'uhalwn ata65.444.32y2ax'.vvdot.govlehsa,wae U.S.OryafMent of NealN OM Humsn Seinaes a10y138y2323 X01565a <br />wmr.mmanagov_ <br />25 <br />