Page 29 - QCS.19 Employee Benefits

cument for more information and a list of any other excluded services.)

• Routine eye care (adult)
when travelling outside the • Routine foot care

• Weight-loss programs

acies

a complete list. Please see your plan document.)
•

t to continue your coverage after it ends. The contact information for those
tion at 1-866-444-3272 or www.dol.gov/ebsa. Other options to continue coverage
h Insurance Marketplace. For more information about the Marketplace, visit

ve a complaint against your plan for a denial of a claim. This complaint is called a
n of benefits you will receive for that medical claim. Your plan documents also
on to your plan. For more information about your rights, this notice, or assistance,

nefits Security Administration at 1-866-444-3272 or

r other coverage, you’ll have to make a payment when you file your tax return
erage for that month.

premium tax creditto help you pay for a plan through the Marketplace.

0-291-2634.

.
r a sample medical situation, see the next section.––––––––––––––––––––––

ument at www.myallsavers.com. 5 of 6