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 immediate medical attention
For emergency services, out-of-network is subject to the in-network benefits.
Urgent care
Deductible then $0
Deductible then $0
Facility fee (e.g., hospital room) Deductible then $0
Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0
––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none ––––––––––– ––––––––––– none –––––––––––
If you have a hospital stay*
Physician/surgeon fees
Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0 Deductible then $0
If you need mental health, behavioral health, or substance abuse services
Outpatient services Inpatient services*
Office visits
Childbirth/delivery professional services
If you are pregnant
Childbirth/delivery facility services
Home health care*
Rehabilitation services Habilitation services Skilled nursing care*
If you need help recovering or have other special health needs
Durable medical equipment
Hospice services*
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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