Do you need a referral No. You can see the specialist you choose without a referral. to see a specialist? All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. 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) Primary care visit to treat an $25/visit deductible does not Not covered Virtual visits (Telehealth) injury or illness apply benefits available. If you visit a Specialist visit $50/visit deductible does not Not covered Virtual visits (Telehealth) health care apply benefits available. provider’s office You may have to pay for services or clinic Preventive care/screening/ that aren't preventive. Ask your immunization No charge Not covered provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood 20% coinsurance Not covered --------none-------- If you have a test work) Imaging (CT/PET scans, MRIs) 20% coinsurance Not covered --------none-------- $5/prescription, deductible Typically Lower Cost Generic does not apply (retail) and Not covered (retail and home (Tier 1a) $10/prescription, deductible delivery) does not apply (home If you need drugs delivery) to treat your $20/prescription, deductible Most home delivery is 90-day illness or does not apply (retail) and Not covered (retail and home supply. For more information, condition Typically Generic (Tier 1b) $40/prescription, deductible delivery) refer to “Essential Drug List” at More information does not apply (home http://www.anthem.com/pharm about prescription delivery) acyinformation/ drug coverage is $40/prescription, deductible *See Prescription Drug section available at Typically Preferred Brand & does not apply (retail) and Not covered (retail and home of the plan or policy document http://www.anthe Non-Preferred Generic Drugs $100/prescription, deductible delivery) (e.g. evidence of coverage or m.com/pharmacyi (Tier 2) does not apply (home certificate). nformation/ delivery) $60/prescription, deductible Typically Non-Preferred Brand does not apply (retail) and Not covered (retail and home and Generic drugs (Tier 3) $150/prescription, deductible delivery) does not apply (home delivery) * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/. Page 2 of 11