3 In addition, Anthem will provide access through its website to the following information: • In-Network negotiated rates; and • Historical Out-of-Network rates. Notice Regarding Retiree-Only Plans If this Plan is issued as part of a retiree-only plan, as defined by ERISA §732(a) and IRC §9831(a)(2), the provisions of the Consolidated Appropriations Act of 2021 will not apply, including the provisions regarding the No Surprises Act. In a retiree-only plan, Out-of-Network Providers may bill you for any charges that exceed the Plan’s Maximum Allowed Amount. Please contact your Employer or former Employer if you are unsure whether your plan is a retiree-only plan.
Anthem Blue Access PPO HSA Option E6 IN PPO Large 96R6 01 01 2025 L12026MR02 L12026 English EOC CY Page 3 Page 5