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Period: 01:101,12017 - 12131,1201:7 <br />City of Lakewood .' Plan: I <br />Summary of Benefits and Coverage: Mat This Plan Covers & What it Costs Coverage for: Single -or Famil�j I Plan Type: PRO: <br />City of Lakewood -. Plan I Coverage Period., :0 110 112017 - 121311-2017 <br />Summary of Benefit-s and :coverage: What This Ptan Covers &What it Costs. Coverage for. Single or Family I Ran Type: PRO <br />Excluded Services .& Othher Covered ServT'Ces: <br />Sec Your Flan Does NOT Cover his 1&Wt a tomplete Ust. Cheok your pol-loy or plan docu meint for other excluded servtces,) <br />Ac-upuncture a 'Hearing Aid-s a Routine Eye C&r_- (Adup"). <br />• Cosmetic Su,-gerj a lnfw. t lit, T. reat M.-.ent * Routine Fo&I Care <br />• Dental check-up (Child) = LongrTermi:CKe * freight Loss Pmgrams <br />• DeenW Care (Adult) f4on-emper,gency care whentraveling outs-ide the <br />• Giasses US - <br />Other Covered Services (This isn't -a complete list Check your policy or plan 4acument f'or other covered services and yourvosts for these semizes.) <br />• Bariatric Surgerj Chi-mpractic Care Private -Duty Nursing <br />Your Rights. to Co.d.tinue Coverage. <br />If you lose co--3ferage. -under the plan,. then, depending upon tie cimumsm''Mes, Fede-m-1 and state laws -may provide promllacbton5 that allorwyou to keep health coverage. Any <br />such ri ghts may be [imilted in-diazation and will require you to pay a which may be signAR-cantly. higher than the premiwn you pzjwhile co"veredunderthe plan- <br />Offier ftitan"Ons on yo- ur rights to continuec, *veragetmay. also apply_ <br />Far more. iinfo-rmati can an you. r rights to continaue cmterage, contact the plan at K 0.540.2-15,83- You may also contact. your state inswance departm. ent, ft U.S_ Departm, ent-of <br />Labar, Emplayee Bens is Secuifity Administration at 866A443'272 Gr the U.S. Depart ment of Heafth and Hums 8erwces at 8.77.26,71323 X61�65 or <br />wmv.cdJo,,,;m5..qo.v_ <br />Me <br />