Anthem Prudent Buyer EPO 3000/25/50/20 (TES)

Your summary of benefits Anthem® Blue Cross Your Plan: Anthem Prudent Buyer EPO 3000/25/50/20 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 Covered Medical Benefits Cost if you use an In-Network Provider Overall Deductible $3,000 person / $6,000 family Overall Out-of-Pocket Limit $7,350 person / $14,700 family To get benefits under this Plan, you must use In-Network Providers. Services from Out-of-Network Providers are not covered, except for Emergency Care, Authorized Services, or when required by law. Please be sure to contact us if you are not sure if we have approved an Authorized Service. 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. 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 $25 copay per visit medical deductible does not Services virtual and office apply Specialist Care virtual and office $50 copay per visit medical deductible does not apply Other Practitioner Visits Maternity services Prenatal and Postnatal care $25 copay per visit medical deductible does not apply Delivery 20% coinsurance after medical deductible is met CA/LG/Anthem Prudent Buyer EPO 3000/25/50/20/8CMY/01-01-2025 Page 1 of 9