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) speech therapy. Preauthorization is required. *See section Therapy: Habilitative and rehabilitative. Inpatient: $200 copay per day up to $600 per 150 inpatient days / year Skilled nursing care individual per admission 40% coinsurance Preauthorization is required. *See section Skilled Professional services: 15% nursing facility. coinsurance Durable medical 15% coinsurance 40% coinsurance None equipment Hospice services No charge 40% coinsurance Hospice care / 6 months 14 respite inpatient or outpatient days / lifetime Children's eye exam No charge, deductible does Not covered 1 routine eye exam / year not apply Limited to individuals under age 19. 1 pair of standard lenses and frames / year If your child needs Children's glasses No charge, deductible does Not covered 1 year supply of contact lenses in lieu of standard dental or eye care not apply lenses and frames Limited to individuals under age 19. Children's dental check- Not covered Not covered None up *For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc. Page 5 of 7