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 areferral and/or prior authorization from the plan .
2022 - 8 - Summary of Benefits H1036265001 
Covered Medical and Hospital Benefits (cont.)  
Hearing Medicare-covered hearing exam:  $25 copay  
Routine hearing:  
In-Network: 
HER691 
•$0 copayment for fitting/evaluation, routine hearing exams up to 1  
per year.