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 Typically Preferred Specialty $250/prescription, deductible Not covered (retail and home (brand and generic) (Tier 4) does not apply (retail and delivery) home delivery) If you have Facility fee (e.g., ambulatory 20% coinsurance Not covered --------none-------- outpatient surgery center) surgery Physician/surgeon fees 20% coinsurance Not covered --------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 $25/visit deductible does not Not covered --------none-------- apply 150 days/benefit period for Inpatient rehabilitation and If you have a Facility fee (e.g., hospital room) 20% coinsurance Not covered skilled nursing services hospital stay combined for In-Network Providers. Physician/surgeon fees 20% coinsurance Not covered --------none-------- Office Visit Office Visit Office Visit 988 lifeline/mobile crisis team $25/visit deductible does not Not covered covered as In-Network. Virtual If you need Outpatient services apply Other Outpatient visits (Telehealth) benefits mental health, Other Outpatient Not covered available. behavioral health, 20% coinsurance Other Outpatient or substance --------none-------- abuse services 20% coinsurance for Inpatient Physician Fee In-Network Inpatient services 20% coinsurance Not covered Providers. No Coverage for Inpatient Physician Fee Non- Network Providers. Office visits $25/visit deductible does not Not covered Maternity care may include tests If you are apply and services described elsewhere pregnant Childbirth/delivery professional 20% coinsurance Not covered in the SBC (i.e., ultrasound). services *Coverage includes fertility * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/. Page 3 of 11