GA Anthem Bronze Pathway X HMO 5000 Coverage Summary

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Dec 6, 2023

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GA/IND/Anthem Bronze Pathway X Guided Access HMO 5000($0 Virtual PCP+$0 Select Drugs)/6RMR/01-23 Page 1 of 11 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2023 - 12/31/2023 Anthem ® BlueCross and BlueShield Coverage for: Individual + Family | Plan Type: HMO Anthem Bronze Pathway X Guided Access HMO 5000($0 Virtual PCP+$0 Select Drugs) The Summary of Benefits and Coverage (SBC) document will help you choose a health plan . The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium ) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, https://eoc.anthem.com/eocdps/6RMRIND01012023 . For general definitions of common terms, such as allowed amount , balance billing , coinsurance , copayment , deductible , provider , or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call (855) 738-6652 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible ? $5,000/person or $10,000/family for In- Network Providers . Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan , each family member must meet their own individual deductible until the total amount of d eductible expenses paid by all family members meets the overall family deductible . Are there services covered before you meet your deductible ? Yes. Primary Care. Preventive Care . Certain Prescription Drugs . Vision. For more information see below. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible . See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ . Are there other deductibles for specific services? No. You don't have to meet deductibles for specific services. What is the out-of - pocket limit for this plan ? $9,100/person or $18,200/family for In- Network Providers . The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan , they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit ? Premiums , balance-billing charges, and health care this plan doesn't cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit . Will you pay less if you use a network provider ? Yes, Pathway Guided Access. See www.anthem.com or call (855) 738-6652 for a list of network providers. Costs may vary by site of service and how the provider bills. This plan uses a provider network . You will pay less if you use a provider in the plan’s network . You will pay the most if you use an out-of-network provider , and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays ( balance billing ). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/6RMRIND01012023 . Page 2 of 11 Do you need a referral to see a specialist ? Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if 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. What You Will Pay Common Medical Event Services You May Need Level 1 Pharmacy- RX Only (You will pay the least) In-Network Provider (You will pay more) Non-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Primary care visit to treat an injury or illness Not Applicable $45/visit deductible does not apply Not covered Virtual visits (Telehealth) benefits available. Specialist visit Not Applicable 25% coinsurance Not covered Virtual visits (Telehealth) benefits available. If you visit a health care provider’s office or clinic Preventive care / screening / immunization Not Applicable No charge Not covered You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood work) Not Applicable 25% coinsurance Not covered --------none-------- If you have a test Imaging (CT/PET scans, MRIs) Not Applicable $500/visit then 50% coinsurance Not covered --------none-------- Generic drugs (Tier 1) $30/prescription, deductible does not apply (retail) and $90/prescription, deductible does not apply (home delivery) $40/prescription, deductible does not apply (retail only) Not covered (retail and home delivery) Preferred brand drugs (Tier 2) 30% coinsurance (retail and home delivery) 45% coinsurance (retail only) Not covered (retail and home delivery) Non-preferred brand drugs (Tier 3) 40% coinsurance (retail and home delivery) 50% coinsurance (retail only) Not covered (retail and home delivery) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at http://www.anthe m.com/pharmacyi nformation/ Specialty drugs (Tier 4) 50% coinsurance (retail and home delivery) 60% coinsurance (retail only) Not covered (retail and home delivery) For more information, refer to “Select Drug List” at http://www.anthem.com/pharm acyinformation/ *See Prescription Drug section

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/6RMRIND01012023 . Page 3 of 11 What You Will Pay Common Medical Event Services You May Need Level 1 Pharmacy- RX Only (You will pay the least) In-Network Provider (You will pay more) Non-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Facility fee (e.g., ambulatory surgery center) Not Applicable 25% coinsurance Not covered --------none-------- If you have outpatient surgery Physician/surgeon fees Not Applicable 25% coinsurance Not covered --------none-------- Emergency room care Not Applicable $500/visit then 25% coinsurance Covered as In- Network Copay waived if admitted. Emergency medical transportation Not Applicable 25% coinsurance Covered as In- Network Non-emergency non- network Ambulance Services are limited to $50,000 per occurrence. If you need immediate medical attention Urgent care Not Applicable $75/visit deductible does not apply Covered as In- Network --------none-------- Facility fee (e.g., hospital room) Not Applicable $500/admission then 50% coinsurance Not covered 60 days/year for Inpatient rehabilitation and skilled nursing services combined for In- Network Providers . If you have a hospital stay Physician/surgeon fees Not Applicable 25% coinsurance Not covered --------none-------- Outpatient services Not Applicable Office Visit 25% coinsurance Other Outpatient 25% coinsurance Office Visit Not covered Other Outpatient Not covered Office Visit Virtual visits (Telehealth) benefits available. Other Outpatient --------none-------- If you need mental health, behavioral health, or substance abuse services Inpatient services Not Applicable $500/admission then 50% coinsurance Not covered --------none-------- Office visits Not Applicable 25% coinsurance Not covered Childbirth/delivery professional services Not Applicable 25% coinsurance Not covered If you are pregnant Childbirth/delivery facility services Not Applicable $500/admission then 50% coinsurance Not covered Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Home health care Not Applicable 25% coinsurance Not covered 120 visits/year In- Network Providers . If you need help recovering or Rehabilitation services Not Applicable 25% coinsurance Not covered *See Therapy Services section.

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* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/6RMRIND01012023 . Page 4 of 11 What You Will Pay Common Medical Event Services You May Need Level 1 Pharmacy- RX Only (You will pay the least) In-Network Provider (You will pay more) Non-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Habilitation services Not Applicable 25% coinsurance Not covered Skilled nursing care Not Applicable $500/admission then 25% coinsurance Not covered 60 days/year for Inpatient rehabilitation and skilled nursing services combined for In- Network Providers . Durable medical equipment Not Applicable 25% coinsurance Not covered *See Durable Medical Equipment Section have other special health needs Hospice services Not Applicable 25% coinsurance Not covered --------none-------- Children’s eye exam Not Applicable No charge Not covered Children’s glasses Not Applicable No charge Not covered *See Vision Services section If your child needs dental or eye care Children’s dental check-up Not Applicable 0% coinsurance Not covered *See Dental Services section Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services . )  Abortion (except in cases of rape, incest, or when the life of the mother is endangered)  Cosmetic surgery  Long-term care  Routine eye care (Adult)  Acupuncture  Dental care (Adult)  Non-emergency care when traveling outside the U.S.  Routine foot care unless medically necessary  Bariatric surgery  Infertility treatment  Private-duty nursing  Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)  Hearing aids 1 item(s)/ear every 48 months for children 18 years of age or under. $3,000 maximum/hearing aid.  Spinal Manipulation 20 visits/year Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Georgia Office of Insurance and Safety Fire Commissioner, Consumer Services Division 2, Martin Luther King, Jr. Drive, WestTower, Suite 716, Atlanta, Georgia 30334, (800) 656-2298, www.oci.ga.gov/ConsumerService/Home.aspx , or contact Anthem at the number on the back of your ID card. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace . For more information about the Marketplace , visit www.HealthCare.gov or call 1-800-318-2596.

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/6RMRIND01012023 . Page 5 of 11 Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim . This complaint is called a grievance or appeal . For more information about your rights, look at the explanation of benefits you will receive for that medical claim . Your plan documents also provide complete information on how to submit a claim , appeal , or a grievance for any reason to your plan . For more information about your rights, this notice, or assistance, contact: ATTN: Grievances and Appeals, P.O. Box 105449, Atlanta, GA 30548-5449 Georgia Office of Insurance and Safety Fire Commissioner, Consumer Services Division, 2 Martin Luther King, Jr. Drive, West Tower, Suite 716, Atlanta, Georgia 30334, (800) 656-2298, www.oci.ga.gov/ConsumerService/Home.aspx Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans , health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage , you may not be eligible for the premium tax credit . Does this plan meet the Minimum Value Standards? Not Applicable If your plan doesn’t meet the Minimum Value Standards , you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace . To see examples of how this plan might cover costs for a sample medical situation, see the next section.

The plan would be responsible for the other costs of these EXAMPLE covered services. Page 6 of 11 Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Mia’s Simple Fracture (in-network emergency room visit and follow up care) Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)  The plan’s overall deductible $5,000  Specialist coinsurance 25%  Hospital (facility) coinsurance 50%  Other coinsurance 25% This EXAMPLE event includes services like: Specialist office visits ( prenatal care ) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests ( ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing Deductibles $5,000 Copayments $10 Coinsurance $3,700 What isn’t covered Limits or exclusions $60 The total Peg would pay is $8,770  The plan’s overall deductible $5,000  Specialist coinsurance 25%  Hospital (facility) coinsurance 50%  Other coinsurance 25% This EXAMPLE event includes services like: Primary care physician office visits ( including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Joe would pay: Cost Sharing Deductibles $4,300 Copayments $500 Coinsurance $0 What isn’t covered Limits or exclusions $20 The total Joe would pay is $4,820  The plan’s overall deductible $5,000  Specialist coinsurance 25%  Hospital (facility) coinsurance 50%  Other coinsurance 25% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost Sharing Deductibles $2,800 Copayments $10 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,810 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts ( deductibles , copayments and coinsurance ) and excluded services under the plan . Use this information to compare the portion of costs you might pay under different health plans . Please note these coverage examples are based on self-only coverage.

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Language Access Services: Page 11 of 11 It’s important we treat you fairly That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368- 1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf . Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

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