Page 47 - Benefits Summary 2018-2019

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
 Acupuncture  Habilitation services  Private-duty nursing

 Bariatric surgery  Hearing aids  Routine eye care (Adult)
 Cosmetic surgery  Infertility treatment  Routine eye care (Children)

 Dental care (Adult)  Long-term care  Routine foot care
 Dental care (Children)  Non-emergency care when traveling outside of the U.S.  Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

 Chiropractic care (20 visits)

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