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) (retail) and $188/prescription, Prescription Drug deductible applies (home delivery) 30% coinsurance up to Typically Preferred Specialty $250/prescription, Not covered (retail and home (brand and generic) (Tier 4) Prescription Drug deductible delivery) applies (retail and home delivery) If you have Facility fee (e.g., ambulatory 25% coinsurance Not covered --------none-------- outpatient surgery center) surgery Physician/surgeon fees No charge Not covered --------none-------- $200/visit then 25% Copayment waived if admitted. Emergency room care coinsurance Covered as In-Network No charge for Emergency Room If you need Physician Fee. immediate Emergency medical $100/trip deductible does not Non-emergency Non-Network medical attention transportation apply Covered as In-Network Ambulance Services are limited to $50,000 per trip. Urgent care $30/visit deductible does not Covered as In-Network --------none-------- apply 150 days/benefit period for Inpatient rehabilitation and If you have a Facility fee (e.g., hospital room) 25% coinsurance Not covered skilled nursing services hospital stay combined for In-Network Providers. Physician/surgeon fees No charge Not covered --------none-------- Office Visit Office Visit Office Visit 988 lifeline/mobile crisis team $30/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, No charge Other Outpatient or substance --------none-------- abuse services No charge for Inpatient Physician Fee In-Network Inpatient services 25% coinsurance Not covered Providers. No Coverage for Inpatient Physician Fee Non- Network Providers. * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/. Page 3 of 11