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
H5216324000SB23 Summary of Benefits 11 H5216324000 
Covered Medical and Hospital Benefits  (cont.) 
IN-NETWORK OUT-OF-NETWORK 
VISION SERVICES 
Medicare-covered vision 
services $30 copay $30 copay 
Medicare-covered diabetic eye 
exam $0 copay $0 copay