How will my health plan pay between the different tiers? This chart below shows you an example of how benefits are paid. As you can see, the deductible, coinsurance, and out-of-pocket maximum is lower when you use HealthSync care providers. Benefit Tier 1 HealthSync care providers (in your plan’s network — lowest costs for you) Tier 2 care providers (in your plan’s network) Tier 3 care providers (not in your plan’s network) Deductible $1,500 $4,500 $13,500 Out-of-pocket maximum $8,500 $8,500 $19,500 Primary care doctor visit $15 copay $40 copay Deductible + 50% coinsurance Specialist visit $30 copay $80 copay Deductible + 50% coinsurance Urgent care $50 copay Deductible + 30% coinsurance Deductible + 50% coinsurance Inpatient Deductible + 10% coinsurance Deductible + 30% coinsurance Deductible + 50% coinsurance Outpatient Deductible + 10% coinsurance Deductible + 30% coinsurance Deductible + 50% coinsurance Emergency $400 + 10% coinsurance Same as preferred Same as preferred Ambulance Deductible + 10% coinsurance Same as preferred Same as preferred What care providers are in the HealthSync network? The HealthSync network includes more than 10,000 care providers and 45 top hospitals throughout Indiana. These include: • Ascension St. Vincent hospitals • Bluffton Regional Medical Center • Dukes Memorial Hospital • Dupont Hospital • Elkhart General Hospital • Franciscan Health • Good Samaritan Hospital • Lutheran Hospital of Indiana • Memorial Hospital of Logansport • Memorial Hospital of South Bend • OrthoIndy • Perry County Memorial Hospital • Schneck Medical Center • Lutheran Downtown Hospital Do I have to use only HealthSync care providers? No, you can use care providers in any of the three tiers. When you use HealthSync providers, you will have the lowest costs. Do I need to get a referral from my primary care provider to see a specialist in the HealthSync network? No, HealthSync plans are open access, which means referrals are not required. What is care provider matching? This service matches you and your dependents with a primary care provider (PCP) and records that PCP in the Anthem system as your assigned PCP. Care providers who participate in HealthSync have agreed to provide a higher level of service to their patients. This includes matching patients with care providers who are: • Best suited to fit their needs. • Able to provide quick access to appointments. • Able to help with referrals and links to specialists and other care providers when needed. • Able to provide top-quality care. • In general practice, family practice, internal medicine, and pediatrics. • Reid Hospital • Lutheran Kosciusko Hospital • The Orthopedic Hospital