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 Private - duty nursing Other Covered Services (Limitations may apply to these services. This isnt 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 Non-emergency care when traveling outside the U.S. 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)