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) www.truescripts.co contact TrueScripts at 844-257- m 1955. If you have Facility fee (e.g., ambulatory 20% coinsurance $250/visit, then 50% coinsurance --------none-------- outpatient surgery center) 40% coinsurance surgery Physician/surgeon fees 20% coinsurance 40% coinsurance 50% coinsurance --------none-------- Emergency room care $250/visit, then $250/visit, then Covered as In- Copayment waived if admitted. 20% coinsurance 20% coinsurance Network If you need Emergency medical Covered as In- Non-emergency Out-of- immediate transportation 20% coinsurance 20% coinsurance Network Network Ambulance Services are medical attention limited to $50,000 per trip $75/visit, Urgent care deductible does not 40% coinsurance 50% coinsurance --------none-------- apply 150 days/benefit period for $500/admission, Inpatient physical medicine, If you have a Facility fee (e.g., hospital room) 20% coinsurance then 40% 50% coinsurance rehabilitation including day hospital stay coinsurance rehabilitation programs and skilled nursing services combined. Physician/surgeon fees 20% coinsurance 40% coinsurance 50% coinsurance --------none-------- Office Visit Office Visit Office Visit $15/visit, $40/visit, Office Visit Virtual visits (Telehealth) If you need Outpatient services deductible does not deductible does not 50% coinsurance benefits available. mental health, apply apply Other Outpatient Other Outpatient behavioral health, Other Outpatient Other Outpatient 50% coinsurance --------none-------- or substance 20% coinsurance 40% coinsurance abuse services $500/admission, Inpatient services 20% coinsurance then 40% 50% coinsurance --------none-------- coinsurance Office visits 20% coinsurance 40% coinsurance 50% coinsurance Childbirth/delivery professional 20% coinsurance 40% coinsurance 50% coinsurance Maternity care may include tests If you are services and services described elsewhere pregnant Childbirth/delivery facility $500/admission, in the SBC (i.e., ultrasound). services 20% coinsurance then 40% 50% coinsurance coinsurance * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 3 of 11