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 H5216107000SB23 H5216107000 
Covered Medical and Hospital Benefits  (cont.) 
IN-NETWORK OUT-OF-NETWORK 
PHYSICAL THERAPY 
Cost share may vary depending 
on the service and where service 
is provided. $20 to  $40 copay 30% of the cost 
AMBULANCE