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 H1036236000SB23 H1036236000 
Covered Medical and Hospital Benefits (cont.)  
OUTPATIENT CARE AND SERVICES 
Diagnostic services, labs and 
imaging 
Cost share may vary depending 
on the service and where service