Page 6 of 8 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.) • Children's glasses • Cosmetic surgery • Dental care (Adult) • Long-term care • Non-emergency care when traveling outside the U.S. • Private-duty nursing Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture (12 visits per calendar year) • Bariatric surgery • Chiropractic care • Hearing aids ($2,000 per ear every 36 months for members age 21 or younger) • Infertility treatment • Routine eye care - adult (one exam every 24 months) • Routine foot care (only for patients with systemic circulatory disease) • Weight loss programs ($150 per calendar year per policy)