How Services Are Covered

	IN NETWORK	OUT OF NETWORK*
Here's What the Plan Pays
Preventive Care**	100% no deductible	65% after deductible (after $500 annual allowance)
Office Visits Primary Care Specialist	85% after deductible	65% after deductible
Emergency Room	85% after deductible	85% after deductible
Hospital	85% after deductible	65% after deductible
Laboratory	85% after deductible	65% after deductible
X-Ray	85% after deductible	65% after deductible
Knee, Hip and Spine Procedures at Anthem Blue Distinction Centers	90% after deductible	No coverage
Travel Expenses	Up to $10,000 reimbursement per occurrence for transportation, food and lodging expenses if a covered medical service under the plan is not available within 75 miles of the participant’s home. Learn more.

_{* Out-of-network expenses are limited to the eligible maximum allowed amount. You are responsible for paying any amount over the eligible maximum allowed amount charges in addition to your deductible and coinsurance.
** Preventive care includes wellness visits for children, preventive exams and recommended screenings for adults and immunizations in or out of network.}