* For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 2 of 7 Will you pay less if you use a network provider? Yes. See www.anthem.com/find - care/?alphaprefix=K6Z or call (833) 578-4441 for a list of network providers. Benefits and costs may vary by site of service and how the provider bills. You pay the least if you use a provider in Preferred Network. You pay more if you use a provider in In-Network. You will pay the most if you use an Out-of-Network Provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an Out-of- Network for some services (such as lab work). Check with your provider before you get services. 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 Preferred Network Provider (You will pay the least) In-Network Provider (You will pay more) 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 $15/visit, deductible does not apply $40/visit, deductible does not apply 50% coinsurance Virtual visits (Telehealth) benefits available. Specialist visit $30/visit, deductible does not apply $80/visit, deductible does not apply 50% coinsurance Virtual visits (Telehealth) benefits available. Preventive care/screening/ immunization No charge No charge 50% 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) No charge No charge 50% coinsurance --------none-------- Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance 50% coinsurance --------none-------- If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.navitus.com . Generic (Tier 1) Retail/Mail Order $10 / $25 copay Not Applicable Carved out to Navitus Preferred Brand (Tier 2) Retail/Mail Order $75 / $187.50 copay Not Applicable Non-Preferred Brand (Tier 3) Retail/Mail Order $150 / $375 copay Not Applicable Specialty (Tier 4) $400 copay Not Applicable