•$0 copay for bitewing x-rays, intraoral x-rays up to 1set(s) per year. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs 
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 .
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H1036236000SB23 Summary of Benefits 9H1036236000