WIXLIB

Anthem Blue CrossYour Plan: Azusa Pacific University: Custom Anthem PPO HSAYour Network: Prudent Buyer PPOCost if you use an InNetwork ProviderCost if you use aNon-NetworkProviderOverall Deductible 2,800 person / 5,400 family 3,500 person / 7,000 familyOut-of-Pocket Limit 3,000 person / 6,000 family 7,000 person / 14,000 familyCovered Medical BenefitsThe family deductible and out-of-pocket maximum are embedded, meaning the cost shares of one family member will beapplied to both per person deductible and per person out-of-pocket maximum; in addition, amounts for all covered familymembers apply to both the family deductible and family out-of-pocket maximum. No one member will pay more than the perperson deductible or per person out-of-pocket maximum.Your copays, coinsurance and deductible count toward your out of pocket amount(s).In-network and out-of-network deductibles and out-of-pocket maximum amounts are separate and do not accumulate towardeach other.Preventive Care / Screening / ImmunizationNo charge40% coinsurance afterdeductible is metPreventive Care for Chronic Conditions per IRS guidelinesNo charge40% coinsurance afterdeductible is metVirtual Care (Telemedicine / Telehealth Visits)Virtual Visits - Online visits with Doctors who also provide services inpersonPrimary Care (PCP) including Mental Health and Substance Abuse care by 20% coinsurance aftera PCPdeductible is met40% coinsurance afterdeductible is metMental Health and Substance Abuse care by Providers other than a PCP20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metSpecialist20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metVirtual Visits from Online Provider LiveHealth Online viawww.livehealthonline.com; our mobile app, website or Anthem-enableddevicePage 1 of 11

Covered Medical BenefitsCost if you use an InNetwork ProviderCost if you use aNon-NetworkProviderPrimary Care (PCP) and Mental Health and Substance Use Disorder20% coinsurance after deductible is metSpecialist Care20% coinsurance after deductible is metVisits in an OfficePrimary Care (PCP)20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metSpecialist Care20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metRoutine Maternity Care (Prenatal and Postnatal)20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metRetail Health Clinic20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metManipulation TherapyCoverage is limited to 30 visits per benefit period.20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metAcupunctureCoverage is limited to 20 visits per benefit period.20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metAllergy Testing20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metChemo/Radiation Therapy20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metDialysis/Hemodialysis20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metPrescription Drugs Dispensed in the officeMaximum of 250 member cost share per drug.20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metSurgery20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metOffice20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metFreestanding Lab20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metOther Practitioner VisitsOther Services in an OfficeDiagnostic ServicesLabPage 2 of 11

Cost if you use an InNetwork ProviderCost if you use aNon-NetworkProvider20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metOffice20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metFreestanding Radiology Center20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metOutpatient Hospital20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metOffice20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metFreestanding Radiology Center20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metOutpatient Hospital20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metUrgent Care20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metEmergency Room Facility Services20% coinsurance afterdeductible is metCovered as In-NetworkEmergency Room Doctor and Other Services20% coinsurance afterdeductible is metCovered as In-NetworkAmbulance20% coinsurance afterdeductible is metCovered as In-Network20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metFacility Fees20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metDoctor Services20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metCovered Medical BenefitsOutpatient HospitalX-RayAdvanced Diagnostic Imaging for example: MRI, PET and CAT scansEmergency and Urgent CareOutpatient Mental Health and Substance Use DisorderDoctor Office VisitFacility VisitPage 3 of 11

Cost if you use an InNetwork ProviderCost if you use aNon-NetworkProviderHospital20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metFreestanding Surgical Center20% coinsurance afterdeductible is met40% coinsurance afterdeductible is met20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metFacility Fees20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metDoctor and other services20% coinsurance afterdeductible is met40% coinsurance afterdeductible is met20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metOffice20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metOutpatient Hospital20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metOffice20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metOutpatient Hospital20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metSkilled Nursing Care (facility)Coverage is limited to 100 days per benefit period.20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metCovered Medical BenefitsOutpatient SurgeryFacility FeesDoctor and Other ServicesHospitalHospital (Including Maternity, Mental Health and Substance UseDisorder)Anthem's maximum payment is up to 1,000 per day for non-emergencyInpatient admissions to Non-Network Providers.Recovery & RehabilitationHome Health CareCoverage is limited to 100 visits per benefit period.Rehabilitation servicesCardiac rehabilitationPage 4 of 11

Cost if you use an InNetwork ProviderCost if you use aNon-NetworkProviderInpatient Hospice20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metDurable Medical Equipment50% coinsurance afterdeductible is met50% coinsurance afterdeductible is metProsthetic Devices20% coinsurance afterdeductible is met40% coinsurance afterdeductible is metCost if you use an InNetwork PharmacyCost if you use aNon-NetworkPharmacyPharmacy DeductibleCombined with medicaldeductibleCombined with medicaldeductiblePharmacy Out-of-Pocket LimitCombined with InNetwork medical outof-pocket limitCombined with NonNetwork medical outof-pocket limitCovered Medical BenefitsCovered Prescription Drug BenefitsPrescription Drug Coverage Cost shares for drugs included on the National drug list appear below. Your plan uses the BaseNetwork. If you select a brand name drug when a generic drug is available, additional cost sharing amounts may apply.Home Delivery Pharmacy Maintenance medication are available through IngenioRx Home Delivery Pharmacy. You will needto call us on the number on your ID card to sign up when you first use the service.Preventive Drugs Your Pharmacy cost share is waived for drugs included on the PreventiveRX Plus drug list, a designated listof drugs for the treatment of diabetes, asthma, depression, heart health, high blood pressure, high cholesterol, andosteoporosis.Tier 1a Preventive - Typically Lower Cost GenericPer 30 day supply (retail pharmacy). Per 90 day supply (home delivery).No charge (retail) andNot covered (homedelivery)40% coinsurancedeductible does notapply (retail) and Notcovered (homedelivery)Tier 1b Preventive - Typically GenericPer 30 day supply (retail pharmacy). Per 90 day supply (home delivery).No charge (retail) andNot covered (homedelivery)40% coinsurancedeductible does notapply (retail) and Notcovered (homedelivery)Tier 2 Preventive - Typically Preferred BrandPer 30 day supply (retail pharmacy). Per 90 day supply (home delivery).No charge (retail) andNot covered (homedelivery)40% coinsurancedeductible does notapply (retail) and NotPage 5 of 11

Covered Prescription Drug BenefitsCost if you use an InNetwork PharmacyCost if you use aNon-NetworkPharmacycovered (homedelivery)Tier 1a - Typically Lower Cost GenericPer 30 day supply (retail pharmacy). Per 90 day supply (home delivery). 5 copay perprescription afterdeductible is met(retail) and 12.50copay per prescriptionafter deductible is met(home delivery)40% coinsurance up to 250 per prescriptionafter deductible is met(retail) and Not covered(home delivery)Tier 1b - Typically GenericPer 30 day supply (retail pharmacy). Per 90 day supply (home delivery). 20 copay perprescription afterdeductible is met(retail) and 50 copayper prescription afterdeductible is met(home delivery)40% coinsurance up to 250 per prescriptionafter deductible is met(retail) and Not covered(home delivery)Tier 2 – Typically Preferred BrandPer 30 day supply (retail pharmacy). Per 90 day supply (home delivery). 30 copay perprescription afterdeductible is met(retail) and 90 copayper prescription afterdeductible is met(home delivery)40% coinsurance up to 250 per prescriptionafter deductible is met(retail) and Not covered(home delivery)Tier 3 - Typically Non-Preferred BrandPer 30 day supply (retail pharmacy). Per 90 day supply (home delivery). 50 copay perprescription afterdeductible is met(retail) and 150 copayper prescription afterdeductible is met(home delivery)40% coinsurance up to 250 per prescriptionafter deductible is met(retail) and Not covered(home delivery)Tier 4 - Typically Specialty (brand and generic)Per 30 day supply (specialty pharmacy).30% coinsurance up to 150 per prescriptionafter deductible is met(retail) and 30%coinsurance up to 250per prescription afterdeductible is met(home delivery)40% coinsurance up to 250 per prescriptionafter deductible is met(retail) and Not covered(home delivery)Page 6 of 11