ANTHEM 3000/6000 BUY-UP PLAN Services In-Network Benefits Network Annual Deductible Individual - $3,000 (E) ▪ BlueCard PPO Network Family - $6,000 (E) Out-of-Pocket Maximum Individual - $5,000 (E) Family - $10,000 (E) Plan Primary Care & Specialist Visit $30 / $45 ▪ 7/1/2021 –6/30/2022 Urgent Care & Walk-In Visits $75 Emergency Room Visit $250 Provider Search Labs Freestanding/SOS: $0 / Office: $30 / $45 www.anthem.com Radiology Freestanding/SOS: $0 / Office: $30 / $45 High-Cost Diagnostics Freestanding: $25 / Office: $45 Additional Information In-Patient Hospitalization 100% Coinsurance after Deductible ▪ Benefits Summary Out-Patient Surgery 100% Coinsurance after Deductible Durable Medical Equipment 50% Coinsurance after Deductible Prescription Drugs Deductible N/A Tier 1 $5 Tier 2 $30 Tier 3 $60 Tier 4 30% to $500 Max per Script Mail Order 3x 12 12