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130% co-insurance —none---- <br />:.................................................................................:.................................................................. <br />Excluded Sent ce <br />........................................................................................................................ <br />Excluded Service <br />00-Vorage for-, 8:Mg---I6,-,,�- Fa-n-t,,!I Pto�.n Type, PPO <br />�zrvice Your Plan Does NOT Cover (This isnIa complete list. Check your policy or plan d-ocurnentfor other excluded services.) <br />• Acupuncture w Cosmetic -Surgery a Dental check-up (Child) <br />• Dental Care (Adult) * Glasses * Hean-nq Aids <br />• Infertility Treatment a Lc Term Gare. 0 Non -emergency care wher, traveling outside the <br />U-S.- <br />• Routine Eye Care (Adult) 4 Routine Foot Care <br />)ther Covered Services (This isnt a complete list. Check your policy or plan. document for other covered services and your costs for thew services.) <br />• BaHatdr, Surgery- s Ghiropractic Care • Private -Duty Nursi-ng <br />• Weight Loss Programs <br />34 <br />