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Combined Evidence of Coverage and Disclosure Form
综合覆盖与披露表证据

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the coverage, https://eoc.anthem.com/eocdps/ca/82D1IND01012025. For general definitions of common terms, such as allowed am coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.heal or call (833) 913-2232 to request a copy.
《利益和覆盖范围概要（SBC）》文档将帮助您选择健康计划。SBC 会向您展示计划将承担的覆盖医疗服务费用。注意：关于此计划（称为）的费用信息将另行提供。这只是一个概要。有关您的覆盖范围更多信息，或获取覆盖范围的副本，请访问 https://eoc.anthem.com/eocdps/ca/82D1IND01012025。有关常见术语的一般定义，例如允许的免赔额、共付金额、自付额、提供者或其他下划线术语，请参阅词汇表。您可以在 www.heal 上查看词汇表，或拨打（833）913-2232 请求副本。
Important Questions  重要问题 Answers  答案 Why This Matters:  为什么这很重要：
What is the overall deductible?
整体免赔额是多少？		 $ 5 , 400 / $ 5 , 400 / $5,400//\$ 5,400 / person or $ 10 , 800 / $ 10 , 800 / $10,800//\$ 10,800 / family for In-Network Providers.
$ 5 , 400 / $ 5 , 400 / $5,400//\$ 5,400 / 个人或 $ 10 , 800 / $ 10 , 800 / $10,800//\$ 10,800 / 家庭，用于网络提供商。		 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 deductible expenses paid by all family members meets the overall family deductible.
一般情况下，您必须支付所有供应商的费用，直到达到自付额之前，此计划才开始支付。如果您在该计划下有其他家庭成员，每个家庭成员都必须满足他们自己的个人自付额，直到所有家庭成员支付的自付额总额达到整体家庭自付额。
Are there services covered before you meet your deductible?
在您满足免赔额之前，有哪些服务是受覆盖的？

是的。初级保健。专科就诊。预防保健。口腔。视力。更多信息请见下文。
Yes. Primary Care. Specialist
Visit. Preventive Care. Dental.
Vision. For more information see below.
Yes. Primary Care. Specialist Visit. Preventive Care. Dental. Vision. For more information see below.| Yes. Primary Care. Specialist | | :--- | | Visit. Preventive Care. Dental. | | 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/.
此计划涵盖一些项目和服务的费用，即使您尚未达到免赔额。但可能需要您支付共付金或共同保险费。例如，此计划在您达到免赔额之前，无需共同付费即可覆盖某些预防性服务。请参阅 https://www.healthcare.gov/coverage/preventive-care-benefits/ 了解覆盖的预防性服务清单。
Are there other deductibles for specific services?
有其他特定服务的扣除额吗？		 Yes. $50/person or $100/family for Prescription Drugs InNetwork Providers. There are no other specific deductibles.
是的。$50/人或$100/家庭，针对网络内药品处方提供商。没有其他特定的免赔额。		 You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
您必须支付这些服务的所有费用，直到达到具体的免赔额，在此计划开始支付这些服务之前。
What is the out-ofpocket limit for this plan?
此计划的自付额上限是多少？		 $ 8 , 700 / $ 8 , 700 / $8,700//\$ 8,700 / person or $ 17 , 400 / $ 17 , 400 / $17,400//\$ 17,400 / family for In-Network Providers.
$ 8 , 700 / $ 8 , 700 / $8,700//\$ 8,700 / 个人或 $ 17 , 400 / $ 17 , 400 / $17,400//\$ 17,400 / 家庭，用于网络提供商。		 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.
自付额上限是指您在一年内为覆盖服务可能支付的最高金额。如果您在本计划中有其他家庭成员，他们必须满足自己的自付额上限，直到整个家庭的自付额上限被满足。
What is not included in the out-of-pocket limit?
不包括在自付限额中的是什么？		 Premiums, balance-billing charges, and health care this plan doesn't cover.
保险费、平衡账单费用以及该计划不涵盖的医疗服务。		 Even though you pay these expenses, they don't count toward the out-of-pocket limit.
尽管您支付了这些费用，但它们不计入自付额上限。
Will you pay less if you use a network provider?
如果你使用网络提供商，你会支付更少吗？		 Yes. See www.anthem.com/findcare / / /// ?alphaprefix = JQO = JQO =JQO=\mathrm{JQO} or call (833) 913-2232 for a list of network providers. Costs may vary by site of service and how the provider bills.
是的。请访问 www.anthem.com/findcare / / /// ?alphaprefix = JQO = JQO =JQO=\mathrm{JQO} 或拨打（833）913-2232 获取网络提供商列表。费用可能因服务地点和提供商的计费方式而异。		 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.
此计划使用提供商网络。如果您在计划网络中使用提供商，您将支付更少。如果您使用网络外的提供商，您将支付最多，并且您可能需要从提供商那里收到一张账单，以反映提供商费用与您的计划支付金额之间的差额（余额账单）。请注意，您的网络提供商可能为某些服务（如实验室检测）使用网络外的提供商。在您接受服务之前，请咨询您的提供商。
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the coverage, https://eoc.anthem.com/eocdps/ca/82D1IND01012025. For general definitions of common terms, such as allowed am coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.heal or call (833) 913-2232 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? $5,400// person or $10,800// 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 deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? "Yes. Primary Care. Specialist Visit. Preventive Care. Dental. 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? Yes. $50/person or $100/family for Prescription Drugs InNetwork Providers. There are no other specific deductibles. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. What is the out-ofpocket limit for this plan? $8,700// person or $17,400// 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. See www.anthem.com/findcare // ?alphaprefix =JQO or call (833) 913-2232 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.| The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the coverage, https://eoc.anthem.com/eocdps/ca/82D1IND01012025. For general definitions of common terms, such as allowed am coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.heal or call (833) 913-2232 to request a copy. | | | | :---: | :---: | :---: | | Important Questions | Answers | Why This Matters: | | What is the overall deductible? | $\$ 5,400 /$ person or $\$ 10,800 /$ 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 deductible expenses paid by all family members meets the overall family deductible. | | Are there services covered before you meet your deductible? | Yes. Primary Care. Specialist <br> Visit. Preventive Care. Dental. <br> 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? | Yes. $50/person or $100/family for Prescription Drugs InNetwork Providers. There are no other specific deductibles. | You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. | | What is the out-ofpocket limit for this plan? | $\$ 8,700 /$ person or $\$ 17,400 /$ 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. See www.anthem.com/findcare $/$ ?alphaprefix $=\mathrm{JQO}$ or call (833) 913-2232 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. |
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.
此计划将支付部分或全部看专科医生的费用，但前提是在看专科医生之前您必须有转诊证明。
I All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
我本图所示的所有共同支付和 coinsurance 费用均为在满足您的免赔额之后，如果适用的话。
Common Medical Event  常见医疗事件 Services You May Need
您可能需要的服务		 What You Will Pay
您将支付的费用		 Limitations, Exceptions, & Other Important Information
限制、例外及其他重要信息
In-Network Provider (You will pay the least)
网络内提供商（您将支付最少）		 Out-of-Network Provider (You will pay the most)
网外服务提供者（您将支付最多）
If you visit a health care provider's office or clinic
如果您访问医疗保健提供者的办公室或诊所		 Primary care visit to treat an injury or illness
初级保健就诊，治疗伤害或疾病		 $ 50 / v i s i t $ 50 / v i s i t $50//visit\$ 50 / v i s i t, deductible does not apply
$ 50 / v i s i t $ 50 / v i s i t $50//visit\$ 50 / v i s i t ，不可扣除		 Not covered  未涵盖 Virtual visits (Telehealth) benefits available.
虚拟访问（远程医疗）福利可用。
Specialist visit  专家访问 $ 90 / v i s i t $ 90 / v i s i t $90//visit\$ 90 / v i s i t, deductible does not apply
$ 90 / v i s i t $ 90 / v i s i t $90//visit\$ 90 / v i s i t ，不可扣除		 Not covered  未涵盖 Virtual visits (Telehealth) benefits available.
虚拟访问（远程医疗）福利可用。
Preventive care/screening/ immunization
预防保健/筛查/免疫接种		 No charge  无需收费 Not covered  未涵盖 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.
您可能需要为非预防性服务付费。询问您的提供商所需的服务是否为预防性。然后检查您的计划将支付什么。
If you have a test
如果您有一个测试		 Diagnostic test (x-ray, blood work)
诊断性检查（X 光，血液检查）

实验室 - 办公室 $ 50 / v i s i t $ 50 / v i s i t $50//visit\$ 50 / v i s i t ，不计免赔额不适用；X 光 - 办公室 $ 95 / v i s i t $ 95 / v i s i t $95//visit\$ 95 / v i s i t ，不计免赔额不适用
Lab - Office
$ 50 / v i s i t $ 50 / v i s i t $50//visit\$ 50 / v i s i t, deductible does not apply
X-Ray - Office
$ 95 / v i s i t $ 95 / v i s i t $95//visit\$ 95 / v i s i t, deductible does not apply
Lab - Office $50//visit, deductible does not apply X-Ray - Office $95//visit, deductible does not apply| Lab - Office | | :--- | | $\$ 50 / v i s i t$, deductible does not apply | | X-Ray - Office | | $\$ 95 / v i s i t$, deductible does not apply |

实验室 - 办公室未覆盖 X 射线 - 办公室未覆盖
Lab - Office
Not covered X-Ray - Office
Not covered
Lab - Office Not covered X-Ray - Office Not covered| Lab - Office | | :--- | | Not covered X-Ray - Office | | Not covered |
 --------none--------  --------无--------
Imaging (CT/PET scans, MRIs)
影像学（CT/PET 扫描、MRI）		 $ 325 / $ 325 / $325//\$ 325 / visit, deductible does not apply
$ 325 / $ 325 / $325//\$ 325 / 访问，不可扣除		 Not covered  未涵盖 --------none--------  --------无--------
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/
如果您需要药物来治疗您的疾病或状况，有关处方药覆盖范围的更多信息可在 http://www.anthe m.com/pharmacyi nformation/ 获取。		 Typically Generic (Tier 1)
通常通用（一级）

18/处方，处方药免赔额不适用（零售）和 54/处方，处方药免赔额不适用（家庭配送）
$18/prescription, Prescription
Drug deductible does not apply (retail) and
$54/prescription, Prescription
Drug deductible does not apply (home delivery)
$18/prescription, Prescription Drug deductible does not apply (retail) and $54/prescription, Prescription Drug deductible does not apply (home delivery)| $18/prescription, Prescription | | :--- | | Drug deductible does not apply (retail) and | | $54/prescription, Prescription | | Drug deductible does not apply (home delivery) |
 Not covered (retail and home delivery)
未涵盖（零售和送货上门）

大多数家庭配送为 90 天用量。更多信息，请参阅 http://www.anthem.com/pharmacyinformation/上的“CA Select IND 药物清单”。*请参阅计划或政策文件中的处方药部分（例如，保险证明或证书）。
Most home delivery is 90 -day supply. For more information, refer to "CA Select IND Drug List" at
http://www.anthem.com/pharm acyinformation/
*See Prescription Drug section of the plan or policy document (e.g. evidence of coverage or certificate).
Most home delivery is 90 -day supply. For more information, refer to "CA Select IND Drug List" at http://www.anthem.com/pharm acyinformation/ *See Prescription Drug section of the plan or policy document (e.g. evidence of coverage or certificate).| Most home delivery is 90 -day supply. For more information, refer to "CA Select IND Drug List" at | | :--- | | http://www.anthem.com/pharm acyinformation/ | | *See Prescription Drug section of the plan or policy document (e.g. evidence of coverage or certificate). |
Typically Preferred Brand & Non-Preferred Generic Drugs (Tier 2)
通常首选品牌药与非首选通用药（第二级）

60 元/处方，适用处方药免赔额（零售）和 $ 180 / $ 180 / $180//\$ 180 / 处方，适用处方药免赔额（居家配送）
$60/prescription, Prescription
Drug deductible applies
(retail) and $ 180 / $ 180 / $180//\$ 180 / prescription, Prescription Drug deductible applies (home delivery)
$60/prescription, Prescription Drug deductible applies (retail) and $180// prescription, Prescription Drug deductible applies (home delivery)| $60/prescription, Prescription | | :--- | | Drug deductible applies | | (retail) and $\$ 180 /$ prescription, Prescription Drug deductible applies (home delivery) |
 Not covered (retail and home delivery)
未涵盖（零售和送货上门）
Typically Non-Preferred Brand and Generic drugs (Tier 3)
通常非首选品牌和通用药物（三级）

90 元/处方，适用处方药免赔额（零售）和 $ 270 / $ 270 / $270//\$ 270 / 处方
$90/prescription, Prescription
Drug deductible applies (retail) and $ 270 / $ 270 / $270//\$ 270 / prescription,
$90/prescription, Prescription Drug deductible applies (retail) and $270// prescription,| $90/prescription, Prescription | | :--- | | Drug deductible applies (retail) and $\$ 270 /$ prescription, |
 Not covered (retail and home delivery)
未涵盖（零售和送货上门）
Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness $50//visit, deductible does not apply Not covered Virtual visits (Telehealth) benefits available. Specialist visit $90//visit, deductible does not apply Not covered Virtual visits (Telehealth) benefits available. Preventive care/screening/ immunization 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. If you have a test Diagnostic test (x-ray, blood work) "Lab - Office $50//visit, deductible does not apply X-Ray - Office $95//visit, deductible does not apply" "Lab - Office Not covered X-Ray - Office Not covered" --------none-------- Imaging (CT/PET scans, MRIs) $325// visit, deductible does not apply Not covered --------none-------- 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/ Typically Generic (Tier 1) "$18/prescription, Prescription Drug deductible does not apply (retail) and $54/prescription, Prescription Drug deductible does not apply (home delivery)" Not covered (retail and home delivery) "Most home delivery is 90 -day supply. For more information, refer to "CA Select IND Drug List" at http://www.anthem.com/pharm acyinformation/ *See Prescription Drug section of the plan or policy document (e.g. evidence of coverage or certificate)." Typically Preferred Brand & Non-Preferred Generic Drugs (Tier 2) "$60/prescription, Prescription Drug deductible applies (retail) and $180// prescription, Prescription Drug deductible applies (home delivery)" Not covered (retail and home delivery) Typically Non-Preferred Brand and Generic drugs (Tier 3) "$90/prescription, Prescription Drug deductible applies (retail) and $270// prescription," Not covered (retail and home delivery) | Common Medical Event | Services You May Need | What You Will Pay | | Limitations, Exceptions, & Other Important Information | | :---: | :---: | :---: | :---: | :---: | | | | In-Network Provider (You will pay the least) | Out-of-Network Provider (You will pay the most) | | | If you visit a health care provider's office or clinic | Primary care visit to treat an injury or illness | $\$ 50 / v i s i t$, deductible does not apply | Not covered | Virtual visits (Telehealth) benefits available. | | | Specialist visit | $\$ 90 / v i s i t$, deductible does not apply | Not covered | Virtual visits (Telehealth) benefits available. | | | Preventive care/screening/ immunization | 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. | | If you have a test | Diagnostic test (x-ray, blood work) | Lab - Office <br> $\$ 50 / v i s i t$, deductible does not apply <br> X-Ray - Office <br> $\$ 95 / v i s i t$, deductible does not apply | Lab - Office <br> Not covered X-Ray - Office <br> Not covered | --------none-------- | | | Imaging (CT/PET scans, MRIs) | $\$ 325 /$ visit, deductible does not apply | Not covered | --------none-------- | | 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/ | Typically Generic (Tier 1) | $18/prescription, Prescription <br> Drug deductible does not apply (retail) and <br> $54/prescription, Prescription <br> Drug deductible does not apply (home delivery) | Not covered (retail and home delivery) | Most home delivery is 90 -day supply. For more information, refer to "CA Select IND Drug List" at <br> http://www.anthem.com/pharm acyinformation/ <br> *See Prescription Drug section of the plan or policy document (e.g. evidence of coverage or certificate). | | | Typically Preferred Brand & Non-Preferred Generic Drugs (Tier 2) | $60/prescription, Prescription <br> Drug deductible applies <br> (retail) and $\$ 180 /$ prescription, Prescription Drug deductible applies (home delivery) | Not covered (retail and home delivery) | | | | Typically Non-Preferred Brand and Generic drugs (Tier 3) | $90/prescription, Prescription <br> Drug deductible applies (retail) and $\$ 270 /$ prescription, | Not covered (retail and home delivery) | |