75 Unlike In - Network Providers, Out - of - Network Providers may send you a bill and collect for the amount of the Provider’s charge that exceeds the Maximum Allowed Amount unless your claim involves a Surprise Billing Claim . You are responsible for paying the difference between the Maximum Allowed Amount and the amount the Provider charges. This amount can be significant. Choosing an In - Network Provider will likely result in lower out - of - pocket costs to you. Please call Member Services for help in finding an I n - Network Provider or visit our website at www.anthem.com . Member Services is also available to assist you in determining this Booklet’s Maximum Allowed Amount for a particular service from an Out - of - Network Provider. In order for us to assist you, you will need to obtain from your Provider the specific procedure code(s) and diagnosis code(s) for the services the Provider will render. You will also need to know the Provider’s charges to calculate your out - of - pocket responsibility. Although Member Services can assist you with this pre - service information, the fin al Maximum Allowed Amount for your claim will be based on the actual claim submitted by the Provider. Member Cost Share For certain Covered Services and depending on your Plan design, you may be required to pay a part of the Maximum Allowed Amount as your cost share amount (for example, Deductible, Copayment, and/or Coinsurance). Your cost share amount and Out - of - Pocket Limits may vary depending on whether you received services from an In - Network or Out - of - Network Provider. Specifically, you may be required to pay higher cost sharing amounts or may have limits on your benefits whe n using Out - of - Network Providers. Please see the “Schedule of Benefits” in this Booklet for your cost share responsibilities and limitations, or call Member Services to learn how this Plan’s benefits or cost share amounts may vary by the type of Provider you use. The Plan will not provide any reimbursement for non - Covered Services. You may be responsible for the total amount billed by your Provider for non - Covered Services, regardless of whether such services are performed by an In - Network or Out - of - Network Provid er. Non - Covered Services include services specifically excluded from coverage by the terms of your Plan and received after benefits have been exhausted Benefits may be exhausted by exceeding, for example, benefit caps or day/visit limits. The following are examples for illustrative purposes only; the amounts shown may be different than this Booklet’s cost share amounts; see your “Schedule of Benefits” for your applicable amounts. Example: Your Plan has a Coinsurance cost share of 20% for In - Network services, and 30% for Out - of - Network services after the In - Network or Out - of - Network Deductible has been met. • You choose an In - Network surgeon. The charge was $2500. The Maximum Allowed Amount for the surgery is $1500; your Coinsurance responsibility when an In - Network surgeon is used is 20% of $1500, or $300. We allow 80% of $1500, or $1200. The In - Network su rgeon accepts the total of $1500 as reimbursement for the surgery regardless of the charges. Your total out - of - pocket responsibility would be $300. • You choose an Out - of - Network surgeon. The Out - of - Network surgeon’s charge for the service is $2500. The Maximum Allowed Amount for the surgery service is $1500; your Coinsurance responsibility for the OUT - OF - NETWORK surgeon is 30% of $1500, or $450 after the OUT - OF - NETWORK Deductible has been met. We allow the remaining 70% of $1500, or $1050. In addition, the Out - of - Network surgeon could bill you the difference between $2500 and $1500, so your total out - of - pocket charge would be $450 plus an additional $1000, for a total of $1450.