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 Telemedicine: Office visits provided via Telemedicine will be paid at 100% of the allowable charge. All other services provided via Telemedicine are subject to the same Cost Sharing provisions as a Non- Telemedicine service.
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
$35 copay/visit
If you visit a health care provider ’ s office or clinic
Specialist visit
$70 copay/visit
$70 copay/visit
––––––––––– none –––––––––––
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.
Tier 1 Tier 2 Tier 3 Tier 4* Tier 5*
$15 copay $50 copay $75 copay
$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
––––––––––– none ––––––––––– ––––––––––– none –––––––––––
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.
$150 copay 20% coinsurance not to exceed $250 Deductible then 20% coinsurance Deductible then 20% coinsurance
Not Covered
Facility fee (e.g., ambulatory surgery center)
Deductible then 20% coinsurance Deductible then 20% coinsurance
––––––––––– none –––––––––––
If you have outpatient surgery
Physician/surgeon fees
––––––––––– 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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