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
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
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 ––––––––––– ––––––––––– none –––––––––––
If you visit a health care provider ’ s office or clinic
Specialist visit
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 Preferred: Deductible then $150 copay Non-Preferred: Deductible then 20% coinsurance not to exceed $250 Deductible then $0 Deductible then $0 Deductible then $0
Generic drugs are mandatory, physician cannot override.
Generic drugs
Preferred brand drugs
––––––––––– none –––––––––––
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbsks.com
Non-preferred brand drugs
––––––––––– 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.
Specialty drugs*
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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