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
6 Summary of Benefits H5216324000SB23 H5216324000 
Monthly Premium, Deductible and Limits 
PLAN COSTS 
Monthly plan premium 
You must keep paying your 
Medicare Part Bpremium. $74 
If you receive premium assistance, your plan 
premium may be reduced.