per year. 
•0% of the cost for periodontal  
maintenance up to 4per year. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs 
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
10 Summary of Benefits H5216324000SB23 H5216324000