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
H5216107000SB23 Summary of Benefits 7H5216107000 
Covered Medical and Hospital Benefits  (cont.) 
IN-NETWORK OUT-OF-NETWORK 
•Bone mass measurement 
•Breast cancer screening  
(mammogram) 
•Cardiovascular disease  
(behavioral therapy) 
•Cardiovascular screenings