Urgent care services $0 copay Not Covered 
Substance abuse or behavioral 
health services $0 copay Not Covered 18 Summary of Benefits H5216324000SB23 H5216324000 
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