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) deductible does not apply. authorization required. Inpatient: 15% coinsurance Inpatient: Prior authorization required. Habilitation services $35 / visit, deductible does not Not covered 60 visit limit / year. Prior authorization apply. required. Skilled nursing care 15% coinsurance Not covered 150 day limit / year. Prior authorization required. Durable medical 20% coinsurance Not covered Subject to formulary guidelines. Prior equipment authorization required. Hospice services No charge, deductible does not Not covered Prior authorization required. apply. Children’s eye exam No charge for refractive exam, Not covered None If your child needs deductible does not apply. dental or eye care Children’s glasses No charge, deductible does not Not covered Limited to one pair of frames and lenses or apply contact lenses / 12 months. Children’s dental checkups Not covered Not covered None Excluded Services & Other Covered Services Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Cosmetic surgery • Long-term care • Dental care (Adult and Child) • Non-emergency care when traveling outside • Routine foot care • Infertility treatment the U.S • Weight loss programs • Private-duty nursing Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture (12 visit limit / year) • Chiropractic care (12 visit limit / year) • Routine eye care (Adult) • Bariatric surgery • Hearing aids ($3,000 limit / ear / 36 months) 12024_1983-101_KWNX_SBC-W-LG-DED-XX_{666604}_{WP24 - WA PEBB DHMO}_912202315325 Rev. (11/16) Page 4 of 6