* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso. 3 of " 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 need immediate medical attention Emergency medical transportation 20% coinsurance Covered as In-Network --------none-------- Urgent care 20% coinsurance 50% coinsurance --------none-------- If you have a hospital stay Facility fee (e.g., hospital room) 20% coinsurance 50% coinsurance --------none-------- Physician/surgeon fees 20% coinsurance 50% coinsurance --------none-------- If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit 20% coinsurance Other Outpatient 20% coinsurance Office Visit 50% coinsurance Other Outpatient 50% coinsurance Office Visit --------none-------- Other Outpatient --------none-------- Inpatient services 20% coinsurance 50% coinsurance --------none-------- If you are pregnant Office visits 20% coinsurance 50% coinsurance Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery professional services 20% coinsurance 50% coinsurance Childbirth/delivery facility services 20% coinsurance 50% coinsurance If you need help recovering or have other special health needs Home health care 20% coinsurance 50% coinsurance --------none-------- Rehabilitation services 20% coinsurance 50% coinsurance *See Therapy Services section Habilitation services 20% coinsurance 50% coinsurance Skilled nursing care 20% coinsurance 50% coinsurance --------none-------- Durable medical equipment 20% coinsurance 20% coinsurance *See Durable Medical Equipment Section Hospice services 20% coinsurance 50% coinsurance --------none-------- If your child needs dental or eye care Children’s eye exam 20% coinsurance 50% coinsurance *See Vision Services section Children’s glasses Not covered Not covered Children’s dental check-up Not covered Not covered *See Dental Services section