What You Will Pay Preferred In-Network Out-of-Network Common Services You May Need Network Provider Provider Limitations, Exceptions, & Medical Event Provider (You will pay (You will pay the Other Important Information (You will pay the more) most) least) 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 Non-emergency Out-of- immediate Emergency medical 20% coinsurance 20% 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 20% coinsurance 40% coinsurance 50% coinsurance --------none-------- $500/admission, 100 days/benefit period for If you have a Facility fee (e.g., hospital room) 20% coinsurance then 40% 50% coinsurance Inpatient physical medicine, hospital stay coinsurance rehabilitation including day rehabilitation programs. Physician/surgeon fees 20% coinsurance 40% coinsurance 50% coinsurance --------none-------- Office Visit Office Visit Office Visit Office Visit If you need 20% coinsurance 40% coinsurance 50% coinsurance Virtual visits (Telehealth) mental health, Outpatient services Other Outpatient Other Outpatient Other Outpatient benefits available. behavioral health, 20% coinsurance 40% coinsurance 50% coinsurance Other Outpatient or substance --------none-------- 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 If you need help Home health care 20% coinsurance 40% coinsurance 50% coinsurance 100 visits/benefit period. recovering or Rehabilitation services 20% coinsurance 40% coinsurance 50% coinsurance *See Therapy Services section. have other Habilitation services 20% coinsurance 40% coinsurance 50% 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