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
8 Summary of Benefits H5216107000SB23 H5216107000 
Covered Medical and Hospital Benefits  (cont.) 
IN-NETWORK OUT-OF-NETWORK 
EMERGENCY CARE 
Emergency room 
If you are admitted to the 
hospital within 24 hours, you do 
not have to pay your share of the