Yes. Find a doctor at ump.regence.com/go/pebb/ump-classic or call This plan uses a provider network. You will pay less if you use a provider in the plan's 1- 888-849-3681 (TRS: 711) for a list of network. You will pay the most if you use an out-of-network provider, and you might Will you pay less if you use network providers (preferred providers). receive a bill from a provider for the difference between the provider's charge and what a network provider? For a list of network pharmacies, visit the your plan pays (balance billing). Be aware, your network provider might use an out-of- pharmacy-locator webpage at network provider for some services (such as lab work). Check with your provider before ump.regence.com/go/2024/pharmacy-locator you get services. or call 1-888-361-1611 (TRS: 711). Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important Event Need In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) Primary care visit to 15% coinsurance 40% coinsurance treat an injury or illness None If you visit a health Specialist visit 15% coinsurance 40% coinsurance care provider's office Coinsurance and deductible do not apply for childhood or clinic Preventive No charge, deductible does 40% coinsurance, immunizations from out-of-network providers. You may care/screening/ not apply deductible does not apply have to pay for services that aren't preventive. Ask immunization your provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, 15% coinsurance 40% coinsurance Certain tests aren’t covered, and other tests require If you have a test blood work) preauthorization. Please refer to your plan document. Imaging (CT/PET scans, 15% coinsurance 40% coinsurance *See section Radiology. MRIs) *For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc. Page 2 of 7