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) calendar year Physician/surgeon fees 20% coinsurance 40% coinsurance Preauthorization may be required. *See section Surgery. Outpatient services 20% 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 20% coinsurance 40% coinsurance Cost sharing does not apply for preventive services. Childbirth/delivery 20% 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