* For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 2 of 7 Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $40/visit, deductible does not apply 30% coinsurance Virtual visits (Telehealth) benefits available. Specialist visit $45/visit, deductible does not apply 30% coinsurance Virtual visits (Telehealth) benefits available. Preventive care/screening/ immunization No charge 30% coinsurance You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance --------none-------- Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance --------none-------- If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.navitus.com Typically Generic (Tier 1) Greater of $10 or 15% coinsurance (retail and home delivery) Greater of $10 or 15% coinsurance (retail) and Not covered (home delivery) *See Prescription Drug section. Typically Preferred Brand & Non-Preferred Generic Drugs (Tier 2) Greater of $40 or 40% coinsurance (retail and home delivery) Greater of $40 or 40% coinsurance (retail) and Not covered (home delivery) Typically Non-Preferred Brand and Generic drugs (Tier 3) Greater of $60 or 60% coinsurance (retail and home delivery) Greater of $60 or 60% coinsurance (retail) and Not covered (home delivery) Typically Preferred Specialty (brand and generic) (Tier 4) 20% coinsurance (retail and home delivery) 30% coinsurance (retail) and Not covered (home delivery) If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) $150/visit; then 20% coinsurance, deductible does not apply 30% coinsurance, deductible does not apply --------none-------- Physician/surgeon fees $150/visit; then 20% coinsurance, deductible does not apply 30% coinsurance, deductible does not apply 20% coinsurance for Outpatient Anesthesia for In-Network Providers. 30% coinsurance for Outpatient Anesthesia for Out- of-Network Providers.