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.
2 of 6
Made with FlippingBook Digital Publishing Software