Group Number
34399000
Provided By
Blue Cross Blue Shield of Kansas City
Provider Website
Customer Service
Resources
Frequently Asked QuestionsMedical Benefits
Your employer offers medical insurance to protect the health of you and your family. It covers medical expenses such as visits to the doctor’s office, emergency care, and prescription drugs. It’s important to have a medical plan that meets your needs and the needs of your family. This plan is available only to employees who live in the Kansas City Metro Area. (Includes Jackson, Clay, Platte, Cass, Clinton, DeKalb, Johnson, Lafayette, Ray and Caldwell in MO. Johnson and Wyandotte in KS)
Keep in mind that your out-of-pocket costs will be lower if you receive care from an in-network doctor and facility. To find an in-network doctor, please visit www.bluekc.com.
In-Network |
Out-of-Network |
|
|---|---|---|
Deductible |
$6,000 / $12,000 |
$12,000 / $24,000 |
Out-of-Pocket Max |
$7,500 / $15,000 |
$20,000 / $40,000 |
Member Coinsurance (Plan pays/You pay) |
80% / 20% |
50% / 50% |
Physician Visits |
||
Primary Care Visit |
$40 Copay |
Deductible + 20% Coinsurance |
Routine Preventive |
$0 |
Deductible + 20% Coinsurance |
Specialist Visit |
$80 Copay |
Deductible + 20% Coinsurance |
Telehealth |
$10 Copay |
N/A |
Hospital Services |
||
Physician Services |
Deductible, then 20% Coinsurance |
Deductible, then 50 % Coinsurance |
Inpatient Hospitalization |
Deductible, then 20% Coinsurance |
Deductible, then 50 % Coinsurance |
Outpatient Surgery |
Deductible, then 20% Coinsurance |
Deductible, then 50 % Coinsurance |
Basic Outpatient Diagnostics |
Deductible, then 20% Coinsurance |
Deductible, then 50 % Coinsurance |
Urgent Care |
$80 Copay |
Deductible, then 50 % Coinsurance |
Emergency Room |
$200 Copay, then Deductible, then |
$200 Copay, then Deductible, then |
Retail Prescriptions |
||
Tier 1-Generic/Generic Specialty |
$15 |
$15 Copay, then 50 % Coinsurance |
Tier 2-Preferred |
$70 |
$70 Copay, then 50 % Coinsurance |
Tier 3-Non-Preferred/Preferred Specialty |
$110 |
$110 Copay, then 50 % Coinsurance |
Tier 4-Non-Preferred Specialty |
$200 |
$200 Copay, then 50 % Coinsurance |
Mail Order Prescriptions |
||
Tier 1-Generic |
$37.50 Copay |
$37.50 Copay, then 50 % Coinsurance |
Tier 2-Preferred |
$175 Copay |
$175 Copay, then 50 % Coinsurance |
Tier 3-Non-Preferred |
$275 Copay |
$275 Copay, then 50 % Coinsurance |
Per Pay Period Cost |
|
|---|---|
Employee Only |
$82.40 |
Employee + Spouse |
$207.68 |
Employee + Child(ren) |
$159.01 |
Employee + Family |
$235.63 |
This plan is available only to employees who live in the Kansas City Metro Area. It is a narrow-network medical plan and offers only in-network coverage, except for emergency care. (Includes Jackson, Clay, Platte, Cass, Clinton, DeKalb, Johnson, Lafayette, Ray and Caldwell in MO. Johnson and Wyandotte in KS)
In-network facilities include Spira Care Centers and BlueSelect Plus providers and hospitals. To find an in-network doctor, please visit www.bluekc.com.
In-Network |
Out-of-Network |
|
|---|---|---|
Deductible |
$5,000 / $10,000 |
N/A |
Out-of-Pocket Max |
$5,000 / $10,000 |
N/A |
Member Coinsurance (Plan pays/You pay) |
100% / 0% |
N/A |
Physician Visits |
||
Primary Care Visit |
Spira Care Center - $0 |
Not Covered |
Routine Preventive |
$0 |
Not Covered |
Specialist Visit |
Spira Care Center - $0 |
Not Covered |
Telehealth |
$10 Copay |
Not Covered |
Hospital Services |
||
Physician Services |
Deductible, then no charge |
Not Covered |
Inpatient Hospitalization |
Deductible, then no charge |
Not Covered |
Outpatient Surgery |
Deductible, then no charge |
Not Covered |
Basic Outpatient Diagnostics |
Deductible, then no charge |
Not Covered |
Urgent Care |
Deductible, then no charge |
Deductible, then no charge |
Emergency Room |
Deductible, then no charge |
Deductible, then no charge |
Retail Prescriptions |
||
Tier 1-Generic/Generic Specialty |
$15 Copay |
Not Covered |
Tier 2-Preferred |
$50 Copay |
Not Covered |
Tier 3-Non-Preferred/Preferred Specialty |
Deductible, then no charge |
Not Covered |
Mail Order Prescriptions |
||
Tier 1-Generic |
$15 Copay |
Not Covered |
Tier 2-Preferred |
$125 Copay |
Not Covered |
Tier 3-Non-Preferred |
Deductible, then no charge |
Not Covered |
Per Pay Period Cost |
|
|---|---|
Employee Only |
$84.16 |
Employee + Spouse |
$212.11 |
Employee + Child(ren) |
$162.41 |
Employee + Family |
$240.66 |
Your employer offers medical insurance to protect the health of you and your family. It covers medical expenses such as visits to the doctor’s office, emergency care, and prescription drugs. It’s important to have a medical plan that meets your needs and the needs of your family. This plan is available only to employees who live in the Kansas City Metro Area. (Includes Jackson, Clay, Platte, Cass, Clinton, DeKalb, Johnson, Lafayette, Ray and Caldwell in MO. Johnson and Wyandotte in KS)
Keep in mind that your out-of-pocket costs will be lower if you receive care from an in-network doctor and facility. To find an in-network doctor, please visit www.bluekc.com.
In-Network |
Out-of-Network |
|
|---|---|---|
Deductible |
$6,000 / $12,000 |
$12,000 / $24,000 |
Out-of-Pocket Max |
$7,500 / $15,000 |
$15,000 / $30,000 |
Member Coinsurance (Plan pays/You pay) |
80% / 20% |
60% / 40% |
Physician Visits |
||
Primary Care Visit |
$40 Copay |
Deductible + 40% Coinsurance |
Routine Preventive |
$0 |
Deductible + 40% Coinsurance |
Specialist Visit |
$80 Copay |
Deductible + 40% Coinsurance |
Telehealth |
$10 Copay |
N/A |
Hospital Services |
||
Physician Services |
Deductible, then 20% Coinsurance |
Deductible, then 40 % Coinsurance |
Inpatient Hospitalization |
Deductible, then 20% Coinsurance |
Deductible, then 40 % Coinsurance |
Outpatient Surgery |
Deductible, then 20% Coinsurance |
Deductible, then 40 % Coinsurance |
Basic Outpatient Diagnostics |
Deductible, then 20% Coinsurance |
Deductible, then 40 % Coinsurance |
Urgent Care |
$80 Copay |
Deductible, then 40 % Coinsurance |
Emergency Room |
$200 Copay, then Deductible, then 20% |
$200 Copay, then Deductible, then 20% |
Retail Prescriptions |
||
Tier 1-Generic/Generic Specialty |
$15 Copay |
$15 Copay, then 50 % Coinsurance |
Tier 2-Preferred |
$70 Copay |
$70 Copay, then 50 % Coinsurance |
Tier 3-Non-Preferred/Preferred Specialty |
$110 Copay |
$110 Copay, then 50 % Coinsurance |
Tier 4-Non-Preferred Specialty |
$200 Copay |
$200 Copay, then 50 % Coinsurance |
Mail Order Prescriptions |
||
Tier 1-Generic |
$37.50 Copay |
$37.50 Copay, then 50 % Coinsurance |
Tier 2-Preferred |
$175 Copay |
$175 Copay, then 50 % Coinsurance |
Tier 3-Non-Preferred |
$275 Copay |
$275 Copay, then 50 % Coinsurance |
Per Pay Period Cost |
|
|---|---|
Employee Only |
$115.37 |
Employee + Spouse |
$290.75 |
Employee + Child(ren) |
$222.62 |
Employee + Family |
$329.88 |
Your employer offers medical insurance to protect the health of you and your family. It covers medical expenses such as visits to the doctor’s office, emergency care, and prescription drugs. It’s important to have a medical plan that meets your needs and the needs of your family.
Keep in mind that your out-of-pocket costs will be lower if you receive care from an in-network doctor and facility. To find an in-network doctor, please visit www.bluekc.com.
In-Network |
Out-of-Network |
|
|---|---|---|
Deductible |
$6,000 / $12,000 |
$12,000 / $24,000 |
Out-of-Pocket Max |
$7,500 / $15,000 |
$15,000 / $30,000 |
Member Coinsurance (Plan pays/You pay) |
80% / 20% |
60% / 40% |
Physician Visits |
||
Primary Care Visit |
$40 Copay |
Deductible + 40% Coinsurance |
Routine Preventive |
$0 |
Deductible + 40% Coinsurance |
Specialist Visit |
$80 Copay |
Deductible + 40% Coinsurance |
Telehealth |
$10 Copay |
N/A |
Hospital Services |
||
Physician Services |
Deductible, then 20% Coinsurance |
Deductible, then 40 % Coinsurance |
Inpatient Hospitalization |
Deductible, then 20% Coinsurance |
Deductible, then 40 % Coinsurance |
Outpatient Surgery |
Deductible, then 20% Coinsurance |
Deductible, then 40 % Coinsurance |
Basic Outpatient Diagnostics |
Deductible, then 20% Coinsurance |
Deductible, then 40 % Coinsurance |
Urgent Care |
$80 Copay |
Deductible, then 40 % Coinsurance |
Emergency Room |
$200 Copay, then Deductible, then |
$200 Copay, then Deductible, then |
Retail Prescriptions |
||
Tier 1-Generic/Generic Specialty |
$15 Copay |
$15 Copay, then 50 % Coinsurance |
Tier 2-Preferred |
$70 Copay |
$70 Copay, then 50 % Coinsurance |
Tier 3-Non-Preferred/Preferred Specialty |
$110 Copay |
$110 Copay, then 50 % Coinsurance |
Tier 4-Non-Preferred Specialty |
$200 Copay |
$200 Copay, then 50 % Coinsurance |
Mail Order Prescriptions |
||
Tier 1-Generic |
$37.50 Copay |
$37.50 Copay, then 50 % Coinsurance |
Tier 2-Preferred |
$175 Copay |
$175 Copay, then 50 % Coinsurance |
Tier 3-Non-Preferred |
$275 Copay |
$275 Copay, then 50 % Coinsurance |
Per Pay Period Cost |
|
|---|---|
Employee Only |
$92.29 |
Employee + Spouse |
$232.60 |
Employee + Child(ren) |
$178.10 |
Employee + Family |
$263.90 |
Group Number
34399000
Provided By
Blue Cross Blue Shield of Kansas City
Provider Website
Customer Service
Resources
Frequently Asked Questions