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) 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 6 of 8