contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the 
plan .
c
H1036236000SB23 Summary of Benefits 9H1036236000 
Covered Medical and Hospital Benefits (cont.)  
•$0 copay for adjustments to dentures, denture rebase, denture  
reline, denture repair, emergency diagnostic exam, tissue  
conditioning up to 1per year. 
•$0 copay for emergency treatment for pain, fluoride treatment, oral