Do you need a referral to see a Yes, but you may self-refer to certain This plan will pay some or all of the costs to see a specialist for covered services but only specialist? specialists. if you have a referral before you see the specialist. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Services You May Need Participating Provider Non-Participating Provider Limitations, Exceptions, & Other Medical Event (You will pay the least) (You will pay the most) Important Information Primary care visit to treat $20 / visit Not covered None an injury or illness If you visit a health Specialist visit $30 / visit Not covered None care provider’s office or clinic You may have to pay for services that aren’t Preventive care/screening/ No charge, deductible does not Not covered preventive. Ask your provider if the services immunization apply. needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, X-ray: 15% coinsurance Not covered None If you have a test blood work) Lab tests: 15% coinsurance Imaging (CT/PET scans, 15% coinsurance Not covered Some services may require prior MRIs) authorization. $15 (retail); $30 (mail order) / Up to a 30-day supply (retail); up to a 90-day Generic drugs prescription Not covered supply (mail order). Subject to formulary If you need drugs guidelines. to treat your illness $40 (retail); $80 (mail order) / Up to a 30-day supply (retail); up to a 90-day or condition Preferred brand drugs prescription Not covered supply (mail order). Subject to formulary More information guidelines. about prescription Up to a 30-day supply (retail); up to a 90-day drug coverage is Non-preferred brand drugs $75 (retail); $150 (mail order) / Not covered supply (mail order). Subject to formulary available at prescription guidelines, when approved through www.kp.org/formulary exception process. 50% coinsurance up to $150 Up to a 30-day supply (retail). Subject to Specialty drugs (retail) / prescription Not covered formulary guidelines, when approved through exception process. If you have Facility fee (e.g., ambulatory 15% coinsurance Not covered Prior authorization required. outpatient surgery surgery center) 12024_1983-204_KWHD_SBC-W-LG-HSA-XX_{666621}_{WPH4 - WA PEBB HDHP}_9122023153218 Rev. (11/16) Page 2 of 6