•Specialist:  $15 copay 
•Urgent care services:  $0 copay 
•Substance abuse and behavioral health services:  $0 copay H1036234000SB23 Summary of Benefits 15 H1036234000 
More benefits with  your plan 
Enjoy some of these extra benefits included in your plan . 
This is asummary of what we cover. It doesn't list every service that we cover or list 
every limitation or exclusion. The Evidence of Coverage (EOC) provides acomplete list of