Provided By
Blue Cross Blue Shield of Kansas City
Provider Website
Customer Service
Resources
Frequently Asked QuestionsMedical Benefits
In-Network |
Out-of-Network |
|
|---|---|---|
Deductible |
$3,000/$6,000 |
$3,000/$6,000 |
Member Coinsurance |
20% |
50% |
Out-of-Pocket Max |
$5,000/$10,000 |
$10,000/$20,000 |
Primary Care Visit |
$40 Copay |
Deductible+Coinsurance |
Specialist Visit |
$40 Copay |
Deductible+Coinsurance |
Diagnostic Testing (X-ray/blood work) |
Deductible+Coinsurance |
Deductible+Coinsurance |
Imaging (CT/PET scans/MRI) |
Deductible+Coinsurance |
Deductible+Coinsurance |
Urgent Care |
$40 Copay |
Deductible+Coinsurance |
Emergency Room |
Deductible+Coinsurance |
Deductible+Coinsurance |
Prescription Drugs |
In-Network |
Out-of-Network |
|---|---|---|
Retail Prescriptions |
||
Generic/Preferred Brand/Non-preferred Brand/Specialty |
$15 / $70 / $110 / $200 |
$15 / $70 / $110 / $200 |
Mail Order Prescriptions |
||
Generic/Preferred Brand/Non-preferred Brand |
$37.50 / $175 / $275 |
$37.50 / $175 / $275 |
Cost per Pay Period (24) |
|
|---|---|
Employee Only |
$128.30 |
Employee + Spouse |
$510.80 |
Employee + Child(ren) |
$472.55 |
Employee + Family |
$969.81 |
In-Network |
Out-of-Network |
|
|---|---|---|
Deductible |
$1,500/$3,000 |
Not Covered |
Out-of-Pocket Max |
$1,500/$3,000 |
Not Covered |
Member Coinsurance |
0% |
Not Covered |
Primary Care Visit |
$0 |
Not Covered |
Specialist Visit |
Deductible |
Not Covered |
Diagnostic Testing (X-ray/blood work) |
$0 |
Not Covered |
Imaging (CT/PET scans/MRI) |
$0 |
Not Covered |
Urgent Care |
$0 |
Not Covered |
Emergency Room |
Deductible |
Not Covered |
Prescription Drugs |
In-Network |
Out-of-Network |
|---|---|---|
Retail Prescriptions |
||
Generic |
$15 |
Not Covered |
Preferred Brand |
$50 |
Not Covered |
Non-preferred Brand & Specialty |
Deductible |
Not Covered |
Mail Order Prescriptions |
||
Generic |
$15 |
Not Covered |
Preferred Brand |
$125 |
Not Covered |
Non-preferred Brand & Specialty |
Deductible |
Not Covered |
Cost per Pay Period (24) |
|
|---|---|
Employee Only |
$123.46 |
Employee + Spouse |
$501.12 |
Employee + Child(ren) |
$463.35 |
Employee + Family |
$954.31 |
In-Network |
Out-of-Network |
|
|---|---|---|
Deductible |
$3,500/$7,000 |
Not Covered |
Out-of-Pocket Max |
$3,500/$7,000 |
Not Covered |
Member Coinsurance |
0% |
Not Covered |
Primary Care Visit |
$0 |
Not Covered |
Specialist Visit |
Deductible |
Not Covered |
Diagnostic Testing (X-ray/blood work) |
$0 |
Not Covered |
Imaging (CT/PET scans/MRI) |
$0 |
Not Covered |
Urgent Care |
$0 |
Not Covered |
Emergency Room |
Deductible |
Not Covered |
Prescription Drugs |
In-Network |
Out-of-Network |
|---|---|---|
Retail Drugs |
||
Generic |
$15 |
Not Covered |
Preferred Brand |
$50 |
Not Covered |
Non-preferred Brand & Specialty |
Deductible |
Not Covered |
Mail Order Drugs |
||
Generic |
$15 |
Not Covered |
Preferred Brand |
$125 |
Not Covered |
Non-preferred Brand & Specialty |
Deductible |
Not Covered |
Cost per Pay Period (24) |
|
|---|---|
Employee Only |
$84.72 |
Employee + Spouse |
$423.65 |
Employee + Child(ren) |
$389.76 |
Employee + Family |
$830.36 |
Provided By
Blue Cross Blue Shield of Kansas City
Provider Website
Customer Service
Resources
Frequently Asked Questions