What Happens If I Go Out of Network?
When you use an out-of-network provider, the plan will pay coinsurance based on Anthem’s maximum allowed amount. You are responsible for any portion of the provider’s charge that exceeds this amount. For example, if you have met your deductible, the plan will pay 65 percent of the maximum allowed amount for out-of-network care.
If your out-of-network provider charges $600 for a procedure and Anthem’s maximum allowed amount for the procedure is $500, you would pay 35 percent of the maximum allowed amount (35% x $500 = $175) plus the $100 that exceeds the maximum allowed amount, for a total of $275.