Page 18 - PWH.19 Employee Benefits

Common Services You May Need W
Medical Event In-Network Prov
Hospice services (You will pay the
If your child Children’s eye exam
needs dental or Children’s glasses 0% coinsuranc
eye care Children’s dental check-up
0% coinsuranc
Not covered
Not covered

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or p

services.)

Abortion Acupuncture

Cosmetic surgery Dental care (adult)

Glasses for a child Hearing aids

Long- term care Routine foot care un

diagnosed with diabe

Other Covered Services (Limitations may apply to these services. This i

Chiropractic care Most coverage provi
States. See www.bcb

Routine eye care (adult)

Your Rights to Continue Coverage: There are agencies that can help if you
agencies is: Ohio Department of Insurance, 50 W. Town Street, Third Floor -
Department of Labor, Employee Benefits Security Administration, (866) 444-
available to you too, including buying individual insurance coverage through th
visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you
called a grievance or appeal. For more information about your rights, look at t
documents also provide complete information to submit a claim, appeal, or a
this notice, or assistance, contact:

ATTN: Grievances and Appeals, P.O. Box 105568, Atlanta GA 30348-5568

Department of Labor, Employee Benefits Security Administration, (866) 444-

Ohio Department of Insurance, 50 W. Town Street, Third Floor - Suite 300, C

* For more information about limitations and exceptions, see plan or policy d