Anthem Classic PPO 500/30/50/20 Summary

Your summary of benefits Anthem® Blue Cross Your Plan: Anthem Classic PPO 500/30/50/20 Your Network: Prudent Buyer PPO Visits with Virtual Care-Only Providers Cost through our mobile app and website Primary Care, and medical services for urgent/acute care No charge medical deductible does not apply Mental Health & Substance Use Disorder Services No charge medical deductible does not apply Specialist care $50 copay per visit medical deductible does not apply Cost if you use an In- Cost if you use a Covered Medical Benefits Network Provider Non-Network Provider Overall Deductible $500 person / $1,500 person / $1,500 family $4,500 family Overall Out-of-Pocket Limit $4,000 person / $12,000 person / $8,000 family $24,000 family The family deductible and out-of-pocket limit are embedded, meaning the cost shares of one family member will be applied to the per person deductible and per person out-of-pocket limit; in addition, amounts for all covered family members apply to both the family deductible and family out-of-pocket limit. No one member will pay more than the per person deductible or per person out-of-pocket limit. All medical and prescription drug deductibles, copayments and coinsurance apply to the out-of-pocket limit. In-Network and Non-Network deductibles and out-of-pocket limit amounts are separate and do not accumulate toward each other. Doctor Visits (virtual and office) You are encouraged to select a Primary Care Physician (PCP). Primary Care (PCP) and Mental Health and Substance Use Disorder $30 copay per visit 40% coinsurance after Services virtual and office medical deductible medical deductible is does not apply met Specialist Care virtual and office $50 copay per visit 40% coinsurance after medical deductible medical deductible is does not apply met CA/LG/Anthem Classic PPO 500/30/50/20/AN9K/01-01-2024 Page 1 of 10