* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso. 2 of " 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 In-Network Provider (You will pay the least) 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 20% coinsurance 50% coinsurance --------none-------- Specialist visit 20% coinsurance 50% coinsurance --------none-------- Preventive care/screening/ immunization 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 (lab work)** 20% coinsurance 50% coinsurance **Lab work is covered at 100% if done at LabCorp, Quest Diagnostic/ LabCard or American Health Network Diagnostic test (x-ray) 20% coinsurance 50% coinsurance --------none-------- Imaging (CT/PET scans, MRIs) 20% coinsurance 50% coinsurance --------none-------- If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.caremark.com or by visiting the BSU website. Tier 1 - Typically Generic Not covered Not covered Carved out to CVS/Caremark Tier 2 - Typically Preferred / Brand Not covered Not covered Tier 3 - Typically Non-Preferred / Specialty Drugs Not covered Not covered Tier 4 - Typically Specialty (brand and generic) Not covered Not covered If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 50% coinsurance --------none-------- Physician/surgeon fees 20% coinsurance 50% coinsurance --------none-------- Emergency room care $200/visit then 20% coinsurance Covered as In-Network Copay waived if admitted.