Common What You Will Pay Limitations, Exceptions, & Other Medical Event Services You May Need Participating Provider Non-Participating Provider Important Information (You will pay the least) (You will pay the most) Physician/surgeon fees 15% coinsurance Not covered Prior authorization required. Emergency room care 15% coinsurance 15% coinsurance None If you need Emergency medical 15% coinsurance 15% coinsurance None immediate medical transportation attention Non-Participating Providers covered when Urgent care $40 / visit Not covered temporarily outside the service area: $40 / visit Facility fee (e.g., hospital 15% coinsurance Not covered Prior authorization required. If you have a room) hospital stay Physician/surgeon fees 15% coinsurance Not covered Prior authorization required. If you need mental Outpatient services $20 / visit Not covered None health, behavioral health, or substance Inpatient services 15% coinsurance Not covered Prior authorization required. abuse services Depending on the type of services, a No charge, deductible does not copayment, coinsurance, or deductible may Office visits apply. Not covered apply. Maternity care may include tests and services described elsewhere in the SBC If you are pregnant (i.e., ultrasound). Childbirth/delivery 15% coinsurance Not covered None professional services Childbirth/delivery facility 15% coinsurance Not covered None services Home health care 15% coinsurance Not covered 130 visit limit / year. Prior authorization required. If you need help Outpatient: $30 / visit Outpatient: 60 visit limit / year. Prior recovering or have Rehabilitation services Inpatient: 15% coinsurance Not covered authorization required. other special needs Inpatient: Prior authorization required. Habilitation services $30 / visit Not covered 60 visit limit / year. Prior authorization required. 12024_1983-204_KWHD_SBC-W-LG-HSA-XX_{666621}_{WPH4 - WA PEBB HDHP}_9122023153218 Rev. (11/16) Page 3 of 6