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Cit�y of Lakewood : Plan I Coveraille II errcr �V/V/M? 112/31/201� <br /> Summary of lBenefits and Coverage: What This Plan Covers&What it Costs Coverage for: Single w,Famiky I Plan Type iPIPO <br /> Excluded Services&Other Covered Services!: <br /> Services Your Plan Does NOT Cover(This isn't'a complete list Check your policy or plan document for other excluded services) <br /> Acupuncture Hearing Aids Routine Eye Care(Adultp <br /> Cosmetic Surgery Infertility Treatment Routine Foot Care <br /> Dental check-up(Child) Long-Teams Cam Weight Loss Programs <br /> Dental Care(Adull Non-emergency care when traveding outso-de the <br /> Gasses U.S. <br /> Other Covered Services(This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services,) <br /> . B@rjatric Surgery Chiropractic Care Primate-Duty Nursing <br /> Your IRigdhta to,Continue Coverage:: <br /> If you lose coverage under,the plan,then, depending upon the riircumstanceSr Fedpraii and State law,may provide protectons that allcw you to keep health coverage. Any <br /> such rights may The limited iin dixation and vjlll require you to pay a premium,whkh may be sqmkantly nrigher than,the premium you pay while covered under the plan. <br /> Other limitations an your rights to�xotmuc coverage may also apply. <br /> FG<r more infwmation cin your rights to continue coverage,contact the plan at 8010.540.2583. You may also contact your state insurance department,the LS.IDepartiment of <br /> Labor,Employee Berafirs Secunty Adiministratron at 866.444.3272 or,,vmj.ddJ.godebsa w the U.S.Department of Health and Human,Services at 877.267.2:323 X61Yb5 or <br /> ffM&.C6i0.CmsgoV. <br /> 33 <br />