Anthem Classic HMO 20/40/500 admit/250 OP SBC

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 04/01/2024 - 03/31/2025 ® Anthem BlueCross Coverage for: Individual + Family | Plan Type: HMO Anthem Classic HMO 20/40/500 admit/250 OP The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, https://eoc.anthem.com/eocdps/. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call (855) 333-5730 to request a copy. Important Questions Answers Why This Matters: What is the overall $0 See the Common Medical Events chart below for your costs for services this plan covers. deductible? Are there services Yes. Primary Care. Specialist This plan covers some items and services even if you haven’t yet met the deductible amount. covered before you Visit. Preventive Care. Certain But a copayment or coinsurance may apply. For example, this plan covers certain preventive meet your deductible? Prescription Drugs. For more services without cost sharing and before you meet your deductible. See a list of covered information see below. preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other No. You don't have to meet deductibles for specific services. deductibles for specific services? What is the out-of- $2,500/person or $5,000/family The out-of-pocket limit is the most you could pay in a year for covered services. If you have pocket limit for this for In-Network Providers. other family members in this plan, they have to meet their own out-of-pocket limits until the plan? overall family out-of-pocket limit has been met. What is not included Premiums, balance-billing Even though you pay these expenses, they don’t count toward the out-of-pocket limit. in the out-of-pocket charges, and health care this plan limit? doesn't cover. Will you pay less if Yes. See This plan uses a provider network. You will pay less if you use a provider in the plan’s you use a network www.anthem.com/find- network. You will pay the most if you use an out-of-network provider, and you might receive provider? care/?alphaprefix=JMV a bill from a provider for the difference between the provider’s charge and what your plan or call (855) 333-5730 for a list of pays (balance billing). Be aware, your network provider might use an out-of-network provider network providers. Costs may for some services (such as lab work). Check with your provider before you get services. vary by site of service and how the provider bills. Do you need a referral Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if to see a specialist? you have a referral before you see the specialist. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. CA/LG/Anthem Classic HMO 20/40/500 admit/250 OP/AN9Z/01-24 Page 1 of 11