Anthem Prudent Buyer PPO Classic 1000/35/55/20 (TES)

Your summary of benefits Anthem® Blue Cross Your Plan: Anthem Prudent Buyer PPO Classic 1000/35/55/20 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 $55 copay per visit medical deductible does not apply Cost if you use an In- Cost if you use an Covered Medical Benefits Network Provider Out-of-Network Provider Overall Deductible $1,000 person / $3,000 person / $3,000 family $9,000 family Overall Out-of-Pocket Limit $5,000 person / $15,000 person / $10,000 family $30,000 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 Out-of-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 $35 copay per visit 40% coinsurance after Services virtual and office medical deductible medical deductible is does not apply met Specialist Care virtual and office $55 copay per visit 40% coinsurance after medical deductible medical deductible is does not apply met Other Practitioner Visits Maternity services CA/LG/Anthem Prudent Buyer PPO Classic 1000/35/55/20/88CH/01-01-2025 Page 1 of 10