What You Will Pay Common Services You May Need In-Network Provider Out-of-Network Provider Limitations, Exceptions, & Medical Event (You will pay the least) (You will pay the most) Other Important Information Urgent care 20% coinsurance 40% coinsurance --------none-------- 100 days/benefit period for Inpatient physical medicine, If you have a Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance rehabilitation including day hospital stay rehabilitation programs and skilled nursing services combined. Physician/surgeon fees 20% coinsurance 40% coinsurance --------none-------- If you need Office Visit Office Visit Office Visit mental health, 20% coinsurance 40% coinsurance Virtual visits (Telehealth) behavioral health, Outpatient services Other Outpatient Other Outpatient benefits available. or substance 20% coinsurance 40% coinsurance Other Outpatient abuse services --------none-------- Inpatient services 20% coinsurance 40% coinsurance --------none-------- Office visits 20% coinsurance 40% coinsurance If you are Childbirth/delivery professional 20% coinsurance 40% coinsurance Maternity care may include tests pregnant services and services described elsewhere Childbirth/delivery facility 20% coinsurance 40% coinsurance in the SBC (i.e., ultrasound). services Home health care 20% coinsurance 40% coinsurance 100 visits/benefit period. Rehabilitation services 20% coinsurance 40% coinsurance *See Therapy Services section. Habilitation services 20% coinsurance 40% coinsurance If you need help 100 days/benefit period for recovering or Inpatient physical medicine, have other Skilled nursing care 20% coinsurance 40% coinsurance rehabilitation including day special health rehabilitation programs and needs skilled nursing services combined. Durable medical equipment 20% coinsurance 40% coinsurance *See Durable Medical Equipment section. Hospice services 20% coinsurance 20% coinsurance --------none-------- If your child Children’s eye exam Not covered Not covered --------none-------- needs dental or Children’s glasses Not covered Not covered eye care Children’s dental check-up Not covered Not covered --------none-------- * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 3 of 10