Network. Glasses Not Covered Not Covered No coverage for Glasses. Dental check-up Not Covered I Not Covered No coverage for Dental check-up. Excluded Services & Other Covered Services: Services Your Plan Does NOT cover (This isn't • Acupuncture • Habilitation services • Bariattic surgery • Infertility treatment • Routine foot

n-Network. Glasses Not Covered Not Covered No coverage for Glasses. Dental check-up Not Covered Not Covered No coverage for Dental check-up. Excluded Services & Other Covered Services: 5006LT090TGS0216tE Services Your Plan Does NOT cover (This isn't a complete list. Check your policy or plan document for other excluded services.)