may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please 
contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the 
plan .
c
H1036235000SB23 Summary of Benefits 11 H1036235000 
Covered Medical and Hospital Benefits  (cont.) 
N/A WHAT YOU PAY ON THIS HUMANA PLAN 
AMBULANCE 
Ambulance $0 copay 
TRANSPORTATION 
N/A $0 copay for plan approved location up to 24 one-way trip(s) per year.