Will you pay less if Yes. See You pay the least if you use a provider in Preferred Network. You pay more if you use a you use a network www.anthem.com/find- provider in In-Network. You will pay the most if you use an Out-of-Network Provider, and provider? care/?alphaprefix=K6Z you might receive a bill from a provider for the difference between the provider’s charge and or call (833) 578-4441 for a list of what your plan pays (balance billing). Be aware, your network provider might use an Out-of- network providers. Costs may Network for some services (such as lab work). Check with your provider before you get vary by site of service and how services. the provider bills. Do you need a referral No. You can see the specialist you choose without a referral. to see a specialist? All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Preferred In-Network Out-of-Network Limitations, Exceptions, & Medical Event Services You May Need Network Provider Provider Provider Other Important Information (You will pay the (You will pay (You will pay the least) more) most) Primary care visit to treat an $15/visit, $40/visit, Virtual visits (Telehealth) injury or illness deductible does not deductible does not 50% coinsurance benefits available. apply apply If you visit a $30/visit, $80/visit, Virtual visits (Telehealth) health care Specialist visit deductible does not deductible does not 50% coinsurance benefits available. provider’s office apply apply or clinic You may have to pay for services Preventive care/screening/ that aren't preventive. Ask your immunization No charge No charge 50% coinsurance provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood No charge No charge 50% coinsurance --------none-------- If you have a test work) Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance 50% coinsurance --------none-------- If you need drugs Generic Drugs (Tier 1) $10 / $25 copay Not Applicable Specialty Drugs are limited to a to treat your Retail/Mail Order max 30-day supply and require a illness or Preferred Brand Drugs (Tier 2) $75 / $187.50 copay Not Applicable prior authorization. condition Retail/Mail Order The specialty drug formulary More information Non-Preferred Brand Drugs $150 / $375 copay Not Applicable changes from time to time. To about prescription (Tier 3) Retail/Mail Order see if your prescription is drug coverage is Specialty Drugs (Tier 4) $400 copay Not Applicable covered under the plan, as well available at Retail/Mail Order as the level of coverage, please * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 2 of 11