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) Value Tier (Specific high 5% coinsurance or Deductible does not apply for insulin. value prescription drugs $10 copay, whichever is 5% coinsurance, deductible *Coinsurance for Tier 2 covered insulins are capped at used to treat certain less / prescription, does not apply $35 per 30-day supply. chronic conditions) deductible does not apply Preauthorization may be required. Please refer to your If you need drugs to 10% coinsurance or plan document. *See section Your prescription drug treat your illness or Tier 1 (Low-cost generic $25 copay, whichever is 10% coinsurance, benefit. condition prescription drugs) less / prescription, deductible does not apply Up to a 90-day supply / retail prescription (your cost More information about deductible does not apply share is per 30-day supply) prescription drug Tier 2 (Preferred brand 30% coinsurance or $75 90-day supply / mail-order prescription drugs and high-cost copay, whichever is less, 30% coinsurance Postal Prescription Services (PPS) and Costco Mail coverage is available at generic drugs) up to 30 day supply / Order Pharmacy are the plan's only network mail-order ump.regence.com/pebb/ prescription* pharmacies. benefits/prescriptions Specialty drugs must be filled from the specialty pharmacy, Ardon Health, except when a drug can only Refer to Value Tier, Tier 1, Refer to Value Tier, Tier 1, be dispensed by a certain pharmacy. Specialty drugs and Tier 2 drugs above. and Tier 2 drugs above. Covers up to a 30-day supply for most specialty prescription drugs. 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. * For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc. Page 3 of 8