Anthem CaliforniaCare HMO Classic 40/60/750 admit/375 OP (TES)

Your summary of benefits Anthem® Blue Cross Your Plan: Anthem CaliforniaCare HMO Classic 40/60/750 admit/375 OP Your Network: California Care HMO Visits with Virtual Care-Only Providers Cost through our mobile app and website Primary Care, and medical services for urgent/acute care No charge Mental Health & Substance Use Disorder Services No charge Specialist care $60 copay per visit Covered Medical Benefits Cost if you use an In-Network Provider Overall Deductible $0 person Overall Out-of-Pocket Limit $2,500 single / $5,000 family To get benefits under this Plan, you must use In-Network Providers. Services from Out-of-Network Providers are not covered, except for Emergency or Urgent Care, Authorized Services, or when required by law. Please be sure to contact us if you are not sure if we have approved an Authorized Service. The family out-of-pocket limit is embedded, meaning each covered person is capped at his or her per single out-of-pocket limit; in addition, cost shares for all covered family members apply to the family out-of-pocket limit, yet no one member will pay more than the per single out-of-pocket limit. All medical and prescription drug deductibles, copayments and coinsurance apply to the out-of-pocket limit. Doctor Visits (virtual and office) Your plan requires the selection of a Primary Care Physician (PCP). A referral from your Primary Care Physician (PCP) is required for Specialist care and most other providers for select covered services. Primary Care (PCP) and Mental Health and Substance Use Disorder $40 copay per visit Services virtual and office Specialist Care virtual and office $60 copay per visit Other Practitioner Visits Maternity services Prenatal and Postnatal care $40 copay per visit Delivery $750 copay per visit CA/LG/Anthem CaliforniaCare HMO Classic 40/60/750 admit/375 OP/8CL2/01-01-2025 Page 1 of 9