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
Deductible then 20% coinsurance
Hospice services*
––––––––––– none –––––––––––
Copay is applicable to the provider type
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
Not Covered Not Covered
––––––––––– none ––––––––––– ––––––––––– none –––––––––––
Children's dental check-up
[* 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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