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) Specialty drugs 15% coinsurance Not covered Prescription drugs filled at excluded pharmacies are not covered. Facility fee (e.g., If you have outpatient ambulatory surgery 15% coinsurance 40% coinsurance None surgery center) Physician/surgeon fees 15% coinsurance 40% coinsurance Preauthorization may be required. *See section Surgery. Emergency room care 15% coinsurance 15% coinsurance In-network deductible applies to in-network and out-of- network services. If you need immediate Coverage is not provided for air or water ambulance if medical attention Emergency medical 20% coinsurance 20% coinsurance ground ambulance would serve the same purpose. transportation Ambulance services for personal or convenience purposes are not covered. Urgent care 15% coinsurance 40% coinsurance None Facility fee (e.g., 15% coinsurance 40% coinsurance Provider must notify plan on admission. If you have a hospital hospital room) stay Physician/surgeon fees 15% coinsurance 40% coinsurance Preauthorization may be required. *See section Surgery. Outpatient services 15% coinsurance 40% coinsurance Preauthorization may be required. *See section If you need mental Behavioral health. health, behavioral Preauthorization required for inpatient admissions. health, or substance Inpatient services 15% coinsurance 40% coinsurance Provider must notify the plan for detoxification, abuse services intensive outpatient program, and partial hospitalization. *See section Behavioral health. Office visits 15% coinsurance 40% coinsurance Cost sharing does not apply for preventive services. Childbirth/delivery 15% coinsurance 40% coinsurance Depending on the type of services, a copayment, If you are pregnant professional services coinsurance or deductible may apply. Maternity care Childbirth/delivery 15% coinsurance 40% coinsurance may include tests and services described elsewhere in facility services the SBC (i.e. ultrasound). *For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc. Page 3 of 6