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
12 Summary of Benefits H5216324000SB23 H5216324000 
Covered Medical and Hospital Benefits  (cont.) 
IN-NETWORK OUT-OF-NETWORK 
Outpatient group and individual 
therapy visits 
Cost share may vary depending