* For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 3 of 11 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) Physician/surgeon fees $150/visit; then 20% coinsurance, deductible does not apply 30% coinsurance, deductible does not apply 20% coinsurance for Outpatient Anesthesia In-Network Providers. 30% coinsurance for Outpatient Anesthesia Out-of- Network Providers. If you need immediate medical attention Emergency room care $200/visit; then 20% coinsurance, deductible does not apply Covered as In-Network Copayment waived if admitted. Emergency medical transportation 20% coinsurance Covered as In-Network --------none-------- Urgent care $40/visit, deductible does not apply 30% coinsurance --------none-------- If you have a hospital stay Facility fee (e.g., hospital room) $200/admission; then 20% coinsurance, deductible does not apply 30% coinsurance, deductible does not apply --------none-------- Physician/surgeon fees $150/visit; then 20% coinsurance, deductible does not apply 30% coinsurance, deductible does not apply 20% coinsurance for Inpatient Anesthesia In-Network Providers. 30% coinsurance for Inpatient Anesthesia Out-of- Network Providers. If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit $45/visit, deductible does not apply Other Outpatient 20% coinsurance Office Visit 30% coinsurance Other Outpatient 40% coinsurance Office Visit Virtual visits (Telehealth) benefits available. Other Outpatient --------none-------- Inpatient services $200/admission; then 20% coinsurance, deductible does not apply 30% coinsurance, deductible does not apply --------none-------- If you are pregnant Office visits $40/visit, deductible does not apply 30% coinsurance Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Childbirth/delivery professional services $150/visit; then 20% coinsurance 30% coinsurance Childbirth/delivery facility services $200/admission; then 20% coinsurance, deductible does not apply 30% coinsurance, deductible does not apply If you need help recovering or Home health care 20% coinsurance 40% coinsurance --------none-------- Rehabilitation services 20% coinsurance 40% coinsurance *See Therapy Services section.