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) 15% coinsurance after $75 15% coinsurance after $75 Copayment applies to facility charge for each visit Emergency room care copay / visit copay / visit (waived if admitted), whether or not the deductible has been met. 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., $200 copay per day up to If you have a hospital hospital room) $600 per individual per 40% coinsurance Provider must notify plan on admission. stay calendar year 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 Behavioral health. If you need mental $200 copay per day up to health, behavioral $600 per individual per Preauthorization required for inpatient admissions. health, or substance Inpatient services calendar year; 40% coinsurance Provider must notify the plan for detoxification, abuse services intensive outpatient program, and partial Professional services: hospitalization. *See section Behavioral health. No charge 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 $200 copay per day up to may include tests and services described elsewhere in facility services $600 per individual per 40% coinsurance the SBC (i.e. ultrasound). calendar year * For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc. Page 4 of 8