Scott County USD 466 Benefit Information 2024-2025

Benefit Information

Community Connected Insurance and Consulting

info@thekbsway.com | 844.763.0535 | www.thekbsway.com

It is time to start enrolling in your employee benefits. To do so, follow the three simple steps below. If you have questions or need assistance, please contact your human resources department. Benefits the KBS Way Click here to visit the enrollment portal. Or type www.kasbebs.org in your browser. Step 1

Step 2

Your username will be your social security number Your pin will be the last four digits of your SSN followed by the last two digits of your birth year.

Step 3

Utilize our easy interface to enroll in your employee benefits. Our digital Benefits Assistant, can help answer questions about specific benefits or plan options.* This gives you the flexibility to enroll at a time that works best for you. As you enroll, the cost per pay period will automatically calculate, so you have all the information you need to enroll in benefits with confidence.

*The Benefits Assistant, only works on Google Chrome and Edge browsers.

info@thekbsway.com | 844.763.0535 | www.thekbsway.com

2024-2025 Rates BCBS - $1500 Deductible

Total Premium

District Pays

Employee Total

Employee Only Employee/Spouse Employee/Children Family

$709.00

$833.33 $698.42 $750.00 $750.00

$1415.67 $10.58 $775.00 $683.00

$2,249.00 $1525.00 $1433.00

BCBS - $3000 Deductible

Total Premium

District Pays

Employee Total

Employee Only Employee/Spouse Employee/Children Family

$683.00

$683.00 $750.00 $750.00 $833.33

$0.00 $719.00 $631.00 $1333.67

$2,167.00 $1469.00 $1381.00

BCBS - $6000 Deductible

Total Premium

District Pays

Employee Total

Employee Only Employee/Spouse Employee/Children Family

$590.00

$590.00 $750.00 $750.00 $833.33

$0.00 $519.00 $1038.67 $443.00

$1269.00 $1193.00 $1,872.00

DENTAL - BCBS

Total Premium

Employer Total

Employee Total

Employee Only Employee/Spouse Employee/Children Family

$136.65 $41.29 $88.60 $89.35

$0.00 $0.00 $0.00 $0.00

$136.65 $41.29 $88.60 $89.35

VISION - Vision Care Direct Platinum

$100/$105

$160/$160

$200/$200

Employee Only Employee +1 Employee/Children Family

$15.30 $24.48 $28.24

$20.00 $32.00 $36.94

$23.58 $37.72 $43.52

$48.04

$62.82

$74.00

Gold

$100/$105

$160/$160

$200/$200

$14.50 $23.22 $26.78 $45.56

$19.22 $30.74 $35.48 $60.34

$22.78 $36.44 $42.06 $71.52

Employee Only Employee +1 Employee/Children Family

Silver

$100/$105

$160/$160

$200/$200

$12.92 $20.68 $23.88 $40.60

$15.28 $24.46 $28.22 $48.00

$17.06 $27.30 $31.50 $53.56

Employee Only Employee +1 Employee/Children Family

Medical Plan Information

Community Connected Insurance and Consulting

Plan 2 NGF

Comprehensive Major Medical

Coverage Period: Beginning on or after 10/01/2024

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Coverage for: Individual/Family| Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsks.com/blueaccess or call 1-800-432-3990. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.bcbsks.com/blueaccess or call 1-800-432-3990 to request a copy.

Important Questions Answers

Why this Matters:

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan , each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible . For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible . See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

What is the overall deductible?

$1,500 person / $3,000 family. Doesn't apply to In-Network preventive care.

Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan?

Yes, preventive care.

No. There are no other specific deductibles . You don ’ t have to meet deductibles for specific services.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan , they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

$6,350 person / $12,700 family.

Premiums , balance-billing charges, and health care this plan doesn ’ t cover. 20% non PPO penalty applies annually up to $2,000 person / $4,000 family.

What is not included in the out-of-pocket limit?

Even though you pay these expenses, they don ’ t count toward the out-of-pocket limit .

This plan uses a provider network . You will pay less if you use a provider in the plan's network . You will pay the most if you use an out-of-network provider , and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays ( balance billing ). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Yes. See www.bcbsks.com /providerdirectory or call 1-800-432-3990 for a list of network providers .

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

specialist you choose without a referral .

No.

You can see the

(DT - OMB control number: 1545- 0047/Expiration Date: 12/31/2019) (DOL - OMB control number: 1210- 0147/Expiration Date:5/31/2022) (HHS - OMB control number: 0938- 1146/Expiration date: 10/31/2022)

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Out-of-Network Provider (You will pay the most)

Network Provider (You will pay the least)

Primary care visit to treat an injury or illness

$35 copay/visit $70 copay/visit

––––––––––– none ––––––––––– ––––––––––– none –––––––––––

If you visit a health care provider ’ s office or clinic

Specialist visit

Preventive care/screening/immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs)

$0. Preventive is without cost share. Deductible then 20% coinsurance Deductible then 20% coinsurance

Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance

Immunizations as identified by the Center of Medicare and Medicaid Services.

––––––––––– none –––––––––––

If you have a test

––––––––––– none –––––––––––

Generic drugs are mandatory, physician cannot override.

Generic drugs

$15 copay $50 copay $75 copay

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbsks.com

Preferred brand drugs

––––––––––– none ––––––––––– ––––––––––– none –––––––––––

Non-preferred brand drugs

Specialty Drugs must be obtained from the Blue Cross and Blue Shield of Kansas Designated Specialty Pharmacy. If a Specialty Prescription Drug is obtained from a Pharmacy other than our Designated Specialty Pharmacy, the drug will not be eligible for benefits.

Preferred: $150 copay Non-Preferred: 20% coinsurance not to exceed $250 Deductible then 20% coinsurance Deductible then 20% coinsurance $200 copay then deductible and 20% coinsurance Deductible then 20% coinsurance

Specialty drugs*

Not Covered

Facility fee (e.g., ambulatory surgery center)

Deductible then 20% coinsurance Deductible then 20% coinsurance $200 copay then deductible and 20% coinsurance Deductible then 20% coinsurance

––––––––––– none –––––––––––

If you have outpatient surgery

Physician/surgeon fees

––––––––––– none –––––––––––

Emergency room care

––––––––––– none –––––––––––

If you need immediate medical attention

Emergency medical transportation

––––––––––– none –––––––––––

[* For more information about limitations and exceptions, see the plan or policy document at www.bcbsks.com.] Questions: Call 1-800-432-3990 or visit us at www.bcbsks.com . If you aren ’ t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-432-3990 to request a copy.

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What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Out-of-Network Provider (You will pay the most)

Network Provider (You will pay the least) Copay is applicable to the provider type Deductible then 20% coinsurance Deductible then 20% coinsurance $35 copay/visit, other outpatient services subject to deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance

If you need immediate medical attention

Copay is applicable to the provider type

Same as office visit. For emergency services, out-of- network is subject to the in-network benefits.

Urgent care

Deductible then 20% coinsurance Deductible then 20% coinsurance

Facility fee (e.g., hospital room)

––––––––––– none –––––––––––

If you have a hospital stay*

Physician/surgeon fees

––––––––––– none –––––––––––

$35 copay/visit, other outpatient services subject to deductible then 20% coinsurance

Outpatient services

––––––––––– none –––––––––––

If you need mental health, behavioral health, or substance abuse services

Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance

Inpatient services*

––––––––––– none –––––––––––

Office visits

––––––––––– none –––––––––––

Childbirth/delivery professional services

If you are pregnant

––––––––––– none –––––––––––

Childbirth/delivery facility services

––––––––––– none –––––––––––

Home health care*

––––––––––– none –––––––––––

Rehabilitation services

––––––––––– none –––––––––––

If you need help recovering or have other special health needs

Habilitation services

––––––––––– none –––––––––––

Skilled nursing care*

––––––––––– none –––––––––––

Durable medical equipment

––––––––––– none –––––––––––

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What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Out-of-Network Provider (You will pay the most)

Network Provider (You will pay the least)

If you need help recovering or have other special health needs

Deductible then 20% coinsurance

Hospice services*

––––––––––– none –––––––––––

Copay is applicable to the provider type

Vision screening for children under 5 years is covered at 100% as preventative.

Children's eye exam

If your child needs dental or eye care

Children's glasses

Not Covered Not Covered

––––––––––– none ––––––––––– ––––––––––– none –––––––––––

Children's dental check-up

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Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover ( Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Bariatric surgery Cosmetic surgery

Dental care (Adult)

Hearing aids

Long-term care

Other Covered Services (Limitation may apply to these services. This isn't a complete list. Please see your plan document.) Infertility treatment Private-duty nursing

Non-emergency care when traveling outside the U.S. See www.bcbs.com/already-a-member/coverage- home-and-away.html

Routine eye care (Adult)

Routine foot care

Spinal manipulations

Weight loss programs

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Blue Cross and Blue Shield of Kansas Customer Service at 1-800-432-3990. You may also contact your state insurance department, Kansas Insurance Department, 1300 SW Arrowhead Road, Topeka, Kansas 66604, Phone: 1-800-432-2484, or visit insurance.kansas.gov, or the Department of Labor's Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Customer Service at 1-800-432-3990 or you can visit www.bcbsks.com/blueaccess, or the Kansas Insurance Department, 1300 SW Arrowhead Road, Topeka, Kansas 66604, Phone: 1-800-432-2484, or visit insurance.kansas.gov, or the Department of Labor's Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn ’ t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

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–––––––––––––––––––––––– To see examples of how this plan might cover costs for a sample medical situation, see the next section. –––––––––– ––––––––––––– PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244- 1850.

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About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) The plan's overall deductible $1,500 Specialist copayment $70 Hospital (facility) coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700

Managing Joe's type 2 Diabetes (a year of routine in-network care of a well- controlled condition) The plan's overall deductible $1,500 Specialist copayment $70 Hospital (facility) coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment Total Example Cost

Mia's Simple Fracture (in-network emergency room visit and follow up care) The plan's overall deductible $1,500 Specialist copayment $70 Hospital (facility) coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray)

Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost

$5,600

$2,800

In this example, Peg would pay: Cost Sharing Deductibles

In this example, Joe would pay: Cost Sharing Deductibles

In this example, Mia would pay: Cost Sharing Deductibles

$1,500

$1,200 $1,100

$1,500

$10

$300 $200

Copayments

$2,200

Coinsurance

What isn't covered

$60

$20

Limits or exclusions

$3,770

$2,320

$2,000

The total Peg would pay is

The total Joe would pay is

The total Mia would pay is

The plan would be responsible for the other costs of these EXAMPLE covered services.

Questions: Call 1-800-432-3990 or visit us at www.bcbsks.com . If you aren ’ t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-432-3990 to request a copy. Blue Cross and Blue Shield of Kansas is an independent licensee of the Blue Cross Blue Shield Association.

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Coverage Period: Beginning on or after 10/01/202 4 Coverage for: Individual/Family| Plan Type: PPO

Plan 2 NGF

Comprehensive Major Medical

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Important Questions Answers

Why this Matters:

What is the overall deductible?

$3, 0 00 person/ $6,000 family. Doesn't apply to In-Network preventive care.

Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan?

Yes, preventive care.

No. There are no other specific deductibles . You don ’ t have to meet deductibles for specific services.

$6,350 person / $12,700 family.

Premiums , balance-billing charges, and health care this plan doesn ’ t cover. 20% non PPO penalty applies annually up to $2,000 person / $4,000 family.

What is not included in the out-of-pocket limit?

Even though you pay these expenses, they don ’ t count toward the out-of-pocket limit .

Yes. See www.bcbsks.com /providerdirectory or call 1-800-432-3990 for a list of network providers .

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

specialist you choose without a referral .

No.

You can see the

(DT - OMB control number: 1545- 0047/Expiration Date: 12/31/2019) (DOL - OMB control number: 1210- 0147/Expiration Date:5/31/2022) (HHS - OMB control number: 0938- 1146/Expiration date: 10/31/2022)

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Out-of-Network Provider (You will pay the most)

Network Provider (You will pay the least)

Primary care visit to treat an injury or illness

$35 copay/visit $70 copay/visit

––––––––––– none ––––––––––– ––––––––––– none –––––––––––

If you visit a health care provider ’ s office or clinic

Specialist visit

Preventive care/screening/immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs)

$0. Preventive is without cost share. Deductible then 20% coinsurance Deductible then 20% coinsurance

Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance

Immunizations as identified by the Center of Medicare and Medicaid Services.

––––––––––– none –––––––––––

If you have a test

––––––––––– none –––––––––––

Generic drugs are mandatory, physician cannot override.

Generic drugs

$15 copay $50 copay $75 copay

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbsks.com

Preferred brand drugs

––––––––––– none ––––––––––– ––––––––––– none –––––––––––

Non-preferred brand drugs

Specialty Drugs must be obtained from the Blue Cross and Blue Shield of Kansas Designated Specialty Pharmacy. If a Specialty Prescription Drug is obtained from a pharmacy other than our Designated Specialty Pharmacy, the drug will not be eligible for benefits.

Specialty drugs*

Not Covered

Facility fee (e.g., ambulatory surgery center)

Deductible then 20% coinsurance Deductible then 20% coinsurance $200 copay then deductible and 20% coinsurance Deductible then 20% coinsurance

––––––––––– none –––––––––––

If you have outpatient surgery

Physician/surgeon fees

––––––––––– none –––––––––––

Emergency room care

––––––––––– none –––––––––––

If you need immediate medical attention

Emergency medical transportation

––––––––––– none –––––––––––

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What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Out-of-Network Provider (You will pay the most)

Network Provider (You will pay the least) Copay is applicable to the provider type Deductible then 20% coinsurance Deductible then 20% coinsurance $35 copay/visit, other outpatient services subject to deductible then 50% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance Deductible then 20% coinsurance

If you need immediate medical attention

Copay is applicable to the provider type

Same as office visit. For emergency services, out-of- network is subject to the in-network benefits.

Urgent care

Deductible then 20% coinsurance Deductible then 20% coinsurance

Facility fee (e.g., hospital room)

––––––––––– none –––––––––––

If you have a hospital stay*

Physician/surgeon fees

––––––––––– none –––––––––––

$35 copay/visit, other outpatient services subject to deductible then 50% coinsurance

Outpatient services

––––––––––– none –––––––––––

If you need mental health, behavioral health, or substance abuse services

Inpatient services*

––––––––––– none –––––––––––

Office visits

––––––––––– none –––––––––––

Childbirth/delivery professional services

If you are pregnant

––––––––––– none –––––––––––

Childbirth/delivery facility services

––––––––––– none –––––––––––

Home health care*

––––––––––– none –––––––––––

Rehabilitation services

––––––––––– none –––––––––––

If you need help recovering or have other special health needs

Habilitation services

––––––––––– none –––––––––––

Skilled nursing care*

––––––––––– none –––––––––––

Durable medical equipment

––––––––––– none –––––––––––

3 of 7

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Out-of-Network Provider (You will pay the most)

Network Provider (You will pay the least)

If you need help recovering or have other special health needs

Deductible then 20% coinsurance

Hospice services*

––––––––––– none –––––––––––

Copay is applicable to the provider type

Vision screening for children under 5 years is covered at 100% as preventative.

Children's eye exam

If your child needs dental or eye care

Children's glasses

Not Covered Not Covered

––––––––––– none ––––––––––– ––––––––––– none –––––––––––

Children's dental check-up

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Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover ( Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Bariatric surgery Cosmetic surgery

Dental care (Adult)

Hearing aids

Long-term care

Other Covered Services (Limitation may apply to these services. This isn't a complete list. Please see your plan document.) Infertility treatment Private-duty nursing

Non-emergency care when traveling outside the U.S. See www.bcbs.com/already-a-member/coverage- home-and-away.html

Routine eye care (Adult)

Routine foot care

Spinal manipulations

Weight loss programs

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About these Coverage Examples:

Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) The plan's overall deductible $3,000 Specialist copayment $70 Hospital (facility) coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700

Managing Joe's type 2 Diabetes (a year of routine in-network care of a well- controlled condition) The plan's overall deductible $3,000 Specialist copayment $70 Hospital (facility) coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment Total Example Cost

Mia's Simple Fracture (in-network emergency room visit and follow up care) The plan's overall deductible $3,000 Specialist copayment $70 Hospital (facility) coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray)

Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost

$5,600

$2,810

In this example, Peg would pay: Cost Sharing Deductibles

In this example, Joe would pay: Cost Sharing Deductibles

In this example, Mia would pay: Cost Sharing Deductibles

$3,000

$1,200 $1,100

$2,800

$10

Copayments

$1,900

Coinsurance

What isn't covered

$60

$20

Limits or exclusions

$4,970

$2,320

$2,810

The total Peg would pay is

The total Joe would pay is

The total Mia would pay is

The plan would be responsible for the other costs of these EXAMPLE covered services.

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Plan 2 NGF

High Deductible Health Plan

Coverage Period: Beginning on or after 10/01/2024

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Coverage for: Individual/Family| Plan Type: PPO

Important Questions Answers

Why this Matters:

What is the overall deductible?

$6,000 person/ $12,000 family. Doesn't apply to In-Network preventive care.

Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan?

Yes, preventive care.

No. There are no other specific deductibles . You don ’ t have to meet deductibles for specific services.

Deductible is $6,000 person / $12,000 family. Total out of pocket max is $6,350 person/ $12,700 family. Premiums , balance-billing charges, and health care this plan doesn ’ t cover. 20% non PPO penalty applies annually up to $2,000 person / $4,000 family.

What is not included in the out-of-pocket limit?

Even though you pay these expenses, they don ’ t count toward the out-of-pocket limit .

Yes. See www.bcbsks.com /providerdirectory or call 1-800-432-3990 for a list of network providers .

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

specialist you choose without a referral .

No.

You can see the

(DT - OMB control number: 1545- 0047/Expiration Date: 12/31/2019) (DOL - OMB control number: 1210- 0147/Expiration Date:5/31/2022) (HHS - OMB control number: 0938- 1146/Expiration date: 10/31/2022)

1 of 6

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Out-of-Network Provider (You will pay the most)

Network Provider (You will pay the least)

Primary care visit to treat an injury or illness

Deductible then $0 Deductible then $0

Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $15 copay Deductible then $50 copay Deductible then $75 copay

––––––––––– none ––––––––––– ––––––––––– none –––––––––––

If you visit a health care provider ’ s office or clinic

Specialist visit

Preventive care/screening/immunization Diagnostic test (x-ray, blood work)

$0. Preventive is without cost share.

Immunizations as identified by the Center of Medicare And Medicaid Services.

Deductible then $0

––––––––––– none ––––––––––– ––––––––––– none –––––––––––

If you have a test

Imaging (CT/PET scans, MRIs) Deductible then $0

Deductible then $15 copay Deductible then $50 copay Deductible then $75 copay Preferred: Deductible then $150 copay Non-Preferred: Deductible then 20% coinsurance not to exceed $250 Deductible then $0 Deductible then $0 Deductible then $0

Generic drugs are mandatory, physician cannot override.

Generic drugs

Preferred brand drugs

––––––––––– none –––––––––––

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbsks.com

Non-preferred brand drugs

––––––––––– none –––––––––––

Specialty drugs*

Not Covered

Facility fee (e.g., ambulatory surgery center)

Deductible then $0 Deductible then $0 Deductible then $0

––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none –––––––––––

If you have outpatient surgery

Physician/surgeon fees Emergency room care Emergency medical transportation

If you need immediate medical attention

Deductible then $0

––––––––––– none –––––––––––

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What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Out-of-Network Provider (You will pay the most)

Network Provider (You will pay the least)

If you need immediate medical attention

For emergency services, out-of-network is subject to the in-network benefits.

Urgent care

Deductible then $0

Facility fee (e.g., hospital room) Deductible then $0

Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0

––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none –––––––––––

If you have a hospital stay*

Physician/surgeon fees

If you need mental health, behavioral health, or substance abuse services

Outpatient services Inpatient services*

Office visits

Childbirth/delivery professional services

If you are pregnant

Childbirth/delivery facility services

Home health care*

Rehabilitation services Habilitation services Skilled nursing care*

If you need help recovering or have other special health needs

Durable medical equipment

Hospice services*

Vision screening for children under 5 years is covered at 100% as preventative.

Children's eye exam

If your child needs dental or eye care

Children's glasses

Not Covered Not Covered

––––––––––– none ––––––––––– ––––––––––– none –––––––––––

Children's dental check-up

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Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover ( Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Bariatric surgery Cosmetic surgery

Dental care (Adult)

Hearing aids

Long-term care

Other Covered Services (Limitation may apply to these services. This isn't a complete list. Please see your plan document.) Infertility treatment Private-duty nursing

Non-emergency care when traveling outside the U.S. See www.bcbs.com/already-a-member/coverage- home-and-away.html

Routine eye care (Adult)

Routine foot care

Spinal manipulations

Weight loss programs

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