Common What You Will Pay Limitations, Exceptions, & Medical Event Services You May Need In-Network Provider Non-Network Provider Other Important Information (You will pay the least) (You will pay the most) 30% coinsurance up to 50% coinsurance up to Typically Preferred Specialty $250/prescription, deductible $250/prescription, deductible (brand and generic) (Tier 4) does not apply (retail and does not apply (retail) and Not home delivery) covered (home delivery) If you have Facility fee (e.g., ambulatory 20% coinsurance 40% coinsurance $350 maximum/admission for outpatient surgery center) Non-Network Providers. surgery Physician/surgeon fees 20% coinsurance 40% coinsurance --------none-------- $150/visit, then 20% Copayment waived if admitted. Emergency room care coinsurance Covered as In-Network 20% coinsurance for Emergency If you need Room Physician Fee. immediate Emergency medical Non-emergency Non-Network medical attention transportation 20% coinsurance Covered as In-Network Ambulance Services are limited to $50,000 per trip. Urgent care $30/visit deductible does not 40% coinsurance --------none-------- apply $500 penalty if Non-Network preauthorization is not obtained. $1,000 maximum/day for Non- If you have a Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Emergency Admissions to Non- hospital stay Network Providers. 150 days/benefit period for Inpatient rehabilitation and skilled nursing services combined. Physician/surgeon fees 20% coinsurance 40% coinsurance --------none-------- Office Visit If you need Office Visit Office Visit 988 lifeline/mobile crisis team mental health, $30/visit deductible does not 40% coinsurance covered as In-Network. Virtual behavioral health, Outpatient services apply Other Outpatient visits (Telehealth) benefits or substance Other Outpatient 40% coinsurance available. abuse services 20% coinsurance Other Outpatient --------none-------- * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/. Page 3 of 12