28 How Your Plan Works Introduction Your Plan is a PPO plan. The Plan has two sets of benefits: In-Network and Out-of-Network. If you choose an In-Network Provider, you will pay less in Out-of-Pocket costs, such as Copayments, Deductibles, and Coinsurance. If you use an Out-of-Network Provider, you will have to pay more Out-of- Pocket costs. To find an In-Network Provider for this Plan, please see “How to Find a Provider in the Network,” later in this section. In-Network Services When you use an In-Network Provider or get care as part of an Authorized Service, Covered Services will be covered at the In-Network level. If you receive Covered Services from an Out-of-Network Provider after we failed to provide you with accurate information in our Provider Directory, or after we failed to respond to your telephone or web- based inquiry within the time required by federal law, your cost share for Covered Services will be based on the In-Network level. Regardless of Medical Necessity, benefits will be denied for care that is not a Covered Service. We, on behalf of the Employer, have final authority to decide the Medical Necessity of the service. In-Network Providers include Primary Care Physicians / Providers (PCPs), Specialists (Specialty Care Physicians / Providers - SCPs), other professional Providers, Hospitals, and other Facilities who contract with us to care for you. Referrals are never needed to visit an In-Network Specialist, including behavioral health Providers. To see a Doctor, call their office: • Tell them you are an Anthem Member, • Have your Member Identification Card handy. The Doctor’s office may ask you for your group or Member ID number. • Tell them the reason for your visit. When you go to the office, be sure to bring your Member Identification Card with you. If you need to see a Specialist, you can visit any In-Network Specialist including a behavioral health Provider. You do not have to get a Referral. For services from In-Network Providers: 1. You will not need to file claims. In-Network Providers will file claims for Covered Services for you. (You will still need to pay any Coinsurance, Copayments, and/or Deductibles that apply.) You may be billed by your In-Network Provider(s) for any non-Covered Services you get or when you have not followed the terms of this Booklet. 2. Precertification will be done by the In-Network Provider. (See the “Getting Approval for Benefits” section for further details.) Please read the “Claims Payment” section for additional information on Authorized Services.