Scott County USD 466 Benefits Guide 2025

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: 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

Deductible then $0

Deductible then $0

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

Specialist visit

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 –––––––––––

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 Deductible then $150 copay Deductible then 20% coinsurance not to exceed $250 Deductible then $0 Deductible then $0 Deductible then $0

Generic drugs are mandatory, physician cannot override.

Tier 1

Tier 2

––––––––––– none –––––––––––

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

Tier 3

––––––––––– 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.

Tier 4* Tier 5*

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

Deductible then $0

––––––––––– 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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