benefit coverage amount per  
year for preventive and  
comprehensive benefits. 
•Benefits received  
out-of-network are subject to  
any in-network benefit  
maximums, limitations, and/or  
exclusions. 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