Medical Benefits

	In-Network	Out-of-Network
Deductible (Individual/Family)	$1,500/$3,000	$3,000/$6,000
Member Coinsurance	20%	50%
Out-of-Pocket Max (Individual/Family)	$3,500/$7,000	$7,000/$14,000
Office Visits
Primary Care	$35 Copay	Deductible + Coinsurance
Specialist	$35 Copay	Deductible + Coinsurance
Urgent Care	$35 Copay	Deductible + Coinsurance
Emergency Room	Deductible + Coinsurance	Deductible + Coinsurance
Prescriptions- Retail
Tier 1	$15 Copay	N/A
Tier 2	$35 Copay	N/A
Tier 3	$70 Copay	N/A
Prescriptions- Mail Order
Tier 1	$37.50 Copay	N/A
Tier 2	$87.50 Copay	N/A
Tier 3	$175 Copay	N/A

	Monthly Rates
Employee Only	$279.20
Employee + Spouse	$702.04
Employee + Child(ren)	$604.53
Employee + Family	$970.26

Downloads

Summary of Benefits

	In-Network	Out-of-Network
Deductible (Individual/Family)	$3,000/$6,000	$6,000/$12,000
Member Coinsurance	20%	50%
Out-of-Pocket Max (Individual/Family)	$5,000/$10,000	$10,000/$20,000
Office Visits
Primary Care	$35 Copay	Deductible+Coinsurance
Specialist	$35 Copay	Deductible+Coinsurance
Urgent Care	$35 Copay	Deductible+Coinsurance
Emergency Room	Deductible+Coinsurance	Deductible+Coinsurance
Prescriptions- Retail
Tier 1	$15 Copay	N/A
Tier 2	$35 Copay	N/A
Tier 3	$70 Copay	N/A
Prescriptions- Mail Order
Tier 1	$37.50 Copay	N/A
Tier 2	$87.50 Copay	N/A
Tier 3	$175 Copay	N/A

	Monthly Rates
Employee Only	$205.04
Employee + Spouse	$543.83
Employee + Child(ren)	$461.60
Family	$758.56

Downloads

Summary of Benefits

	In-Network
Deductible (Individual/Family)	$2,500/$5,000
Member Coinsurance	0%
Out-of-Pocket Max (Individual/Family)	$2,500/$5,000
Office Visits
Primary Care	$0 Spira; otherwise Deductible
Specialist	Deductible
Urgent Care	$0 Spira; otherwise Deductible
Emergency Room	Deductible
Prescriptions- Retail
Tier 1	$15 Copay
Tier 2	$50 Copay
Tier 3	Deductible
Prescriptions- Mail Order
Tier 1	$15 Copay
Tier 2	$125 Copay
Tier 3	Deductible

	Monthly Rates
Employee + Only	$159.20
Employee + Spouse	$446.03
Employee + Child(ren)	$373.27
Family	$627.72

Downloads

Summary of Benefits

	In-Network
Deductible (Individual/Family)	$3,500/$7,000
Member Coinsurance	0%
Out-of-Pocket Max (Individual/Family)	$3,500/$7,000
Office Visits
Primary Care	$0 Spira; otherwise Deductible
Specialist	Deductible
Urgent Care	$0 Spira; otherwise Deductible
Emergency Room	Deductible
Prescriptions- Retail
Tier 1	$15 Copay
Tier 2	$50 Copay
Tier 3	Deductible
Prescriptions- Mail Order
Tier 1	$15 Copay
Tier 2	$125 Copay
Tier 3	Deductible

Rates
Employee Only	$109.46
Employee + Spouse	$339.93
Employee + Child(ren)	$277.40
Family	$485.72

Downloads

Summary of Benefits

	In-Network	Out-of-Network
Deductible (Individual/Family)	$3,500/$7,000	$7,000/$14,000
Member Coinsurance	0%	70%
Out-of-Pocket Max (Individual/Family)	$3,500/$7,000	$17,500/$35,000
Office Visits
Primary Care	Deductible	Deductible
Specialist	Deductible	Deductible
Urgent Care	Deductible	Deductible
Emergency Room	Deductible	Deductible
Prescriptions- Retail
Tier 1	Deductible	N/A
Tier 2	Deductible	N/A
Tier 3	Deductible	N/A
Prescriptions- Mail Order
Tier 1	Deductible	N/A
Tier 2	Deductible	N/A
Tier 3	Deductible	N/A

	Monthly Rate
Employee Only	$148.34
Employee + Spouse	$422.87
Employee + Child(ren)	$352.32
Employee + Family	$596.69

Downloads

Summary of Benefits

Provided By

Blue Cross and Blue Shield of Kansas City

Provider Website

https://bluekc.com

Customer Service

Resources

Frequently Asked Questions