Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Long-term care Routine eye care (Adult) Dental care (Adult) Non-emergency care when traveling outside Routine foot care Infertility treatment the U.S. Private-duty nursing Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture (if prescribed for rehabilitation Chiropractic care Most coverage provided outside the United purposes) Hearing aids States. See www.[insert] Bariatric surgery Weight loss programs Questions: Call 1-800-[insert] or visit us at www.[insert]. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 5 of 8 at www.[insert] or call 1-800-[insert] to request a copy.