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
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 –––––––––––
[* 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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