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) If you have Facility fee (e.g., ambulatory 0% coinsurance $250/visit, then 50% coinsurance --------none-------- outpatient surgery center) 20% coinsurance surgery Physician/surgeon fees 0% coinsurance 20% coinsurance 50% coinsurance --------none-------- Emergency room care $250/visit $250/visit Covered as In- Copayment waived if admitted. Network If you need Non-emergency Out-of- immediate Emergency medical 0% coinsurance 0% coinsurance Covered as In- Network Ambulance Services are medical attention transportation Network limited to $50,000 per trip, does not apply to air ambulance. Urgent care $75/visit $150/visit, then 50% coinsurance --------none-------- 20% coinsurance $500/admission, 100 days/benefit period for If you have a Facility fee (e.g., hospital room) 0% coinsurance then 20% 50% coinsurance Inpatient physical medicine, hospital stay coinsurance rehabilitation including day rehabilitation programs. Physician/surgeon fees 0% coinsurance 20% coinsurance 50% coinsurance --------none-------- Office Visit Office Visit Office Visit Office Visit If you need $15/visit $40/visit, then 20% 50% coinsurance Virtual visits (Telehealth) mental health, Outpatient services Other Outpatient coinsurance Other Outpatient benefits available. behavioral health, 0% coinsurance Other Outpatient 50% coinsurance Other Outpatient or substance 20% coinsurance --------none-------- abuse services $500/admission, Inpatient services 0% coinsurance then 20% 50% coinsurance --------none-------- coinsurance Office visits 0% coinsurance 20% coinsurance 50% coinsurance Childbirth/delivery professional 0% coinsurance 20% 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 0% coinsurance then 20% 50% coinsurance coinsurance If you need help Home health care 0% coinsurance 20% coinsurance 50% coinsurance 100 visits/benefit period. recovering or Rehabilitation services $30/visit $80/visit, then 20% 50% coinsurance have other coinsurance *See Therapy Services section. special health Habilitation services $30/visit $80/visit, then 20% 50% coinsurance needs 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