Medical Benefits

Member Coinsurance

0%

Deductible
(Individual/Family)

$7,000/$14,000

Out-of-Pocket Max
(Individual/Family)

$7,000/$14,000

Doctor Office Visits

Preventive Care

Covered at 100%

Primary Care

Spira Center $0
BSP: Deductible

Specialist Visit

Deductible

Blue KC Virtual Care

$0

Hospital Care:
Inpatient & Outpatient

Deductible

Urgent Care

Deductible

Ambulance

Deductible

Emergency Room

Deductible

Retail

Tier 1

$15 Copay

Tier 2

$50 Copay

Tier 3

Deductible

Tier 4

N/A

Mail Order Drugs

Tier 1

$15 Copay

Tier 2

$125 Copay

Tier 3

Deductible

Employee Only

$74.43

Employee + Spouse

$370.15

Employee + Child(ren)

$268.93

Employee + Family

$528.07

Member Coinsurance

0%

Deductible
(Individual/Family)

$3,500/$7,000

Out-of-Pocket Max
(Individual/Family)

$3,500/$7,000

Doctor Office Visit

Preventive

Covered at 100%

Primary Care

Spira Center $0
BSP: Deductible

Specialist Visit

Deductible

Blue KC Virtual Care

$0

Hospital Care:
Inpatient & Outpatient

Deductible

Urgent Care

Deductible

Ambulance

Deductible

Emergency Room

Deductible

Retail

Tier 1

$15 Copay

Tier 2

$50 Copay

Tier 3

Deductible

Tier 4

N/A

Mail Order

Tier 1

$15 Copay

Tier 2

$125 Copay

Tier 3

Deductible

Employee Only

$104.43

Employee + Spouse

$433.18

Employee + Child(ren)

$325.95

Employee + Family

$624.10

Member Coinsurance

20%

40%

Deductible
(Individual/Family)

$3,000 / $6,000

$3,000 / $6,000

Out-of-Pocket Max
(Individual/Family)

$5,000 / $10,000

$10,000 / $20,000

Doctor Office Visit

Preventive Care

Covered at 100%

Deductible + 50%

Primary Care

$40 Copay

Deductible + 40%

Specialist

$40 Copay

Deductible + 40%

Blue KC Virtual Care

$10 Copay

Not Applicable

Hospital Care:
Inpatient & Outpatient

Deductible + 20%

Deductible + 20%

Urgent Care

$40 Copay

Deductible + 40%

Ambulance

Deductible + 20%

Deductible + 20%

Emergency Room

$100 Copay, Deductible + 20%

$100 Copay, Deductible + 20%

Retail

Tier 1

$15 Copay

Network Copay
+ 50% Coinsurance

Tier 2

$70 Copay

Network Copay
+ 50% Coinsurance

Tier 3

$110 Copay

Network Copay
+ 50% Coinsurance

Tier 4

$200 Copay

Network Copay
+ 50% Coinsurance

Mail Order

Tier 1

$37.50 Copay

Network Copay
+ 50% Coinsurance

Tier 2

$175 Copay

Network Copay
+ 50% Coinsurance

Tier 3

$275 Copay

Network Copay
+ 50% Coinsurance

Employee Only

$138.20

Employee + Spouse

$504.07

Employee + Child(ren)

$390.09

Employee + Family

$732.13

Member Coinsurance

20%

40%

Deductible
(Individual/Family)

$1,500 / $4,500

$1,500 / $4,500

Out-of-Pocket Max
(Individual/Family)

$4,500 / $9,000

$9,000 / $18,000

Doctor Office Visit

Preventive Care

Covered at 100%

Deductible + 50%

Primary Care

$35 Copay

Deductible + 40%

Specialist

$35 Copay

Deductible + 40%

Blue KC Virtual Care

$10 Copay

Not Applicable

Hospital Care:
Inpatient & Outpatient

Deductible + 20%

Deductible + 40%

Urgent Care

$35 Copay

Deductible + 40%

Ambulance

Deductible + 20%

Deductible + 20%

Emergency Room

$100 Copay, Deductible + 20%

$100 Copay, Deductible + 20%

Retail

Tier 1

$15 Copay

Network Copay
+ 50% Coinsurance

Tier 2

$70 Copay

Network Copay
+ 50% Coinsurance

Tier 3

$110 Copay

Network Copay
+ 50% Coinsurance

Tier 4

$200 Copay

Network Copay
+ 50% Coinsurance

Mail Order

Tier 1

$37.50 Copay

Network Copay
+ 50% Coinsurance

Tier 2

$175 Copay

Network Copay
+ 50% Coinsurance

Tier 3

$275 Copay

Network Copay
+ 50% Coinsurance

Employee Only

$153.20

Employee + Spouse

$535.58

Employee + Child(ren)

$418.60

Employee + Family

$780.15