About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) The plan's overall deductible $6,000 Specialist deductible $6,000 Hospital (facility) deductible $6,000 Other deductible $6,000 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700
Managing Joe's type 2 Diabetes (a year of routine in-network care of a well- controlled condition) The plan's overall deductible $6,000 Specialist deductible $6,000 Hospital (facility) deductible $6,000 Other deductible $6,000 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment Total Example Cost
Mia's Simple Fracture (in-network emergency room visit and follow up care) The plan's overall deductible $6,000 Specialist deductible $6,000 Hospital (facility) deductible $6,000 Other deductible $6,000 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray)
Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost
$5,600
$2,800
In this example, Peg would pay: Cost Sharing Deductibles
In this example, Joe would pay: Cost Sharing Deductibles
In this example, Mia would pay: Cost Sharing Deductibles
$6,000
$5,400
$2,800
$10
$0 $0
$0 $0
Copayments
Copayments
Copayments
$0
Coinsurance
Coinsurance
Coinsurance
What isn't covered
What isn't covered
What isn't covered
$60
$20
$0
Limits or exclusions
Limits or exclusions
Limits or exclusions
$6,070
$5,420
$2,800
The total Peg would pay is
The total Joe would pay is
The total Mia would pay is
The plan would be responsible for the other costs of these EXAMPLE covered services.
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. Blue Cross and Blue Shield of Kansas is an independent licensee of the Blue Cross Blue Shield Association.
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