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 9H5216324000 
Covered Medical and Hospital Benefits  (cont.) 
IN-NETWORK OUT-OF-NETWORK 
Routine hearing HER941 
•$0 copay for routine hearing 
exams up to 1per year. 
•$699 copay for each Advanced 
level hearing aid up to 1per ear