Anthem Blue Cross: Summary of Benefits

CA/LG/Anthem Virtual Access Plus Prudent Buyer PPO 3000/30/60/8000/9LMT/01-01-2026 Page 1 of 10 Your summary of benefits Anthem® Blue Cross Your Plan: Anthem Virtual Access Plus Prudent Buyer PPO 3000/30/60/8000 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 $60 copay per visit medical deductible does not apply Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use an Out-of-Network Provider Overall Deductible $3,000 person / $6,000 family $9,000 person / $18,000 family Overall Out-of-Pocket Limit $8,000 person / $16,000 family $24,000 person / $48,000 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 Services virtual and office virtual-No charge medical deductible does not apply office-$30 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Specialist Provider virtual and office $60 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Other Practitioner Visits Maternity services Prenatal and Postpartum care $30 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met