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) $200 copay then deductible and 20% coinsurance Deductible then 20% coinsurance 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
$200 copay then deductible and 20% coinsurance Deductible then 20% coinsurance
Emergency room care
––––––––––– none –––––––––––
If you need immediate medical attention
Emergency medical transportation
––––––––––– none –––––––––––
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
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 –––––––––––
[* 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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