Cost if you use a Cost if you use an In- Cost if you use an Covered Medical Benefits Preferred Network Network Provider Out-of-Network Provider Provider Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Freestanding Radiology Center 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Outpatient Hospital 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Emergency and Urgent Care Urgent Care includes doctor services. $75 copay per visit 40% coinsurance after 50% coinsurance after Additional charges may apply depending on the deductible does not deductible is met deductible is met care provided. apply Emergency Room Facility Services $250 copay per visit $250 copay per visit Covered as In-Network Your copay will be waived if admitted. and then 20% and then 20% coinsurance after coinsurance after deductible is met deductible is met Emergency Room Doctor and Other 20% coinsurance after 20% coinsurance after Covered as In-Network Services deductible is met deductible is met Ambulance 20% coinsurance after 20% coinsurance after Covered as In-Network Authorized Out-of-Network non-emergency deductible is met deductible is met ambulance services are limited to an Anthem maximum payment of $50,000 per trip. Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Doctor Services 20% coinsurance after 40% coinsurance after 50% coinsurance after deductible is met deductible is met deductible is met Outpatient Surgery Facility Fees Hospital 20% coinsurance after $250 copay per visit 50% coinsurance after deductible is met and then 40% deductible is met coinsurance after deductible is met Page 3 of 10