Do you need a referral Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if to see a specialist? you have a referral before you see the 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 $30/visit deductible does not Not covered Virtual visits (Telehealth) injury or illness apply benefits available. If you visit a Specialist visit $60/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 No charge Not covered --------none-------- If you have a test work) Imaging (CT/PET scans, MRIs) $100/service deductible does Not covered --------none-------- not apply $5/prescription, Prescription Drug deductible does not Typically Lower Cost Generic apply (retail) and Not covered (retail and home (Tier 1a) $10/prescription, Prescription delivery) If you need drugs Drug deductible does not to treat your apply (home delivery) Most home delivery is 90-day illness or $20/prescription, Prescription supply. For more information, condition Drug deductible does not refer to “Essential Drug List” at More information Typically Generic (Tier 1b) apply (retail) and Not covered (retail and home http://www.anthem.com/pharm about prescription $40/prescription, Prescription delivery) acyinformation/ drug coverage is Drug deductible does not *See Prescription Drug section available at apply (home delivery) of the plan or policy document http://www.anthe $50/prescription, Prescription (e.g. evidence of coverage or m.com/pharmacyi Typically Preferred Brand & Drug deductible applies Not covered (retail and home certificate). nformation/ Non-Preferred Generic Drugs (retail) and $125/prescription, delivery) (Tier 2) Prescription Drug deductible applies (home delivery) Typically Non-Preferred Brand $75/prescription, Prescription Not covered (retail and home and Generic drugs (Tier 3) Drug deductible applies delivery) * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/. Page 2 of 11