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 $25 / visit, deductible does not Not covered None an injury or illness apply. If you visit a health Specialist visit $35 / visit, deductible does not Not covered None care provider’s apply. 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. X-ray: $10 / visit, deductible Diagnostic test (x-ray, does not apply. Not covered None If you have a test blood work) Lab tests: $10 / visit, deductible does not apply. Imaging (CT/PET scans, $10 / visit, deductible does not Not covered Some services may require prior MRIs) apply. authorization. $15 (retail); $30 (mail order) / Up to a 30-day supply (retail); up to a 90-day Generic drugs prescription, deductible does not Not covered supply (mail order). Subject to formulary If you need drugs apply. 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, deductible does not Not covered supply (mail order). Subject to formulary More information apply. guidelines. about prescription $75 (retail); $150 (mail order) / Up to a 30-day supply (retail); up to a 90-day drug coverage is Non-preferred brand drugs prescription, deductible does not Not covered supply (mail order). Subject to formulary available at apply. guidelines, when approved through www.kp.org/formulary exception process. Specialty drugs 50% coinsurance up to $150 Not covered Up to a 30-day supply (retail). Subject to (retail) / prescription, deductible formulary guidelines, when approved 12024_1983-101_KWNX_SBC-W-LG-DED-XX_{666604}_{WP24 - WA PEBB DHMO}_912202315325 Rev. (11/16) Page 2 of 6