* For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 2 of 6 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 10% coinsurance 30% coinsurance Virtual visits (Telehealth) benefits available. Specialist visit 10% coinsurance 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) 10% coinsurance 40% coinsurance --------none-------- Imaging (CT/PET scans, MRIs) 10% coinsurance 40% coinsurance --------none-------- If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.[insert]. Typically Generic (Tier 1) Not Covered Not Covered Carved out to Navitus. Typically Preferred Brand & Non-Preferred Generic Drugs (Tier 2) Not Covered Not Covered Typically Non-Preferred Brand and Generic drugs (Tier 3) Not Covered Not Covered Typically Preferred Specialty (brand and generic) (Tier 4) Not Covered Not Covered If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 10% coinsurance 30% coinsurance --------none-------- Physician/surgeon fees 10% coinsurance 30% coinsurance --------none-------- If you need immediate medical attention Emergency room care $150/visit, then 10% coinsurance Covered as In-Network Copayment waived if admitted. Emergency medical transportation 20% coinsurance Covered as In-Network --------none-------- Urgent care 10% coinsurance 30% coinsurance --------none-------- If you have a hospital stay Facility fee (e.g., hospital room) 10% coinsurance 30% coinsurance --------none-------- Physician/surgeon fees 10% coinsurance 30% coinsurance --------none--------