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Excluded Services & Other Covered Services: <br />Service Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan documentfor other excluded services.) <br />• Acupuncture <br />• Cosmetic Surgery <br />Dental check-up(Child) <br />• Dental Ca e(Adult) <br />• Classes <br />Hearing Aids <br />• Inredility Treatment <br />• Long -Term Care <br />Nan -emergency care when (raveling outside the <br />U8_ <br />• Routine Eye Cam (Adult) <br />• Routine Foot Care <br />Other Covered Services (This isn't a complete list. Check your policyor plan document for other covered services and your costs for these services.) <br />• Bonaire Surgery Chiropractic Care Pdvate4)uty Nursing <br />• Weight Loss Programs <br />YourRightsto Continue Coverage: <br />If you lose coverage under the plan, then, depending upon the cimumstances, Federal and Stale laws may provide prommo ns that allow, you to keep health coverage_ Any <br />such rights may be limited in duration and will require you to pay it rem which may be significantly higher than the premium you paywhile covered under the plan. <br />Other limitations on your rights to continue coverage may also apply. <br />For more intonation on your rights to continue coverage, contact the also at 800.232,7400. You may also contact your state insurance department, (he U.S. Department of <br />Labor, Employee Benefits Security Administration at 866.444.3272 a vnaw.dol.govmbsa, or the U.S. Department of Health and Human Services at 877 2672323 X61565 or <br />www-cciiomnstuay. <br />Your Grievance and Appeals Rights: <br />If you have a complaint or are dissatisfied with a denial of coverage localisms under your plan, you maybe aWe o a eal a file a rlg evance. For questions about your <br />rights, this notice, or assistance, you can contact: the plan at 800232,7400. <br />Language Access Services 800.232.7400 <br />Questions Call 800,2327400 e visit us if f edMulual,c mlSob - <br />Ifyma.en. cea: alerui any afhe Galded ors vsalin lh fans..., tre 6lo'sar7.Yw can rir-x ln.e i;l�sary „v-r <br />aC Wt JtAutual,cgniSBC a ca_ 800 232-74) lorequ si a copy. _ <br />55 <br />