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
Primary Care Visit	$35 Copay	Deductible + Coinsurance
Specialist Visit	$35 Copay	Deductible + Coinsurance
Urgent Care	$35 Copay	Deductible + Coinsurance
Emergency Room	Deductible + Coinsurance	Deductible + Coinsurance

Retail Prescription Drugs	In-Network
Tier 1	$15 Copay
Tier 2	$35 Copay
Tier 3	$70 Copay
Mail Order Prescription Drugs
Tier 1	$37.50 Copay
Tier 2	$87.50 Copay
Tier 3	$175 Copay

	Monthly Rates
Employee Only	$320.27
Employee + Spouse	$805.32
Employee + Child(ren)	$693.47
Employee + Family	$1,113.00

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Summary of Benefits

Medical Benefit Summary

Nayya Employee Choose

	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
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
Tier 2	$35 Copay
Tier 3	$70 Copay

Prescriptions - Mail Order
Tier 1	$37.50 Copay
Tier 2	$87.50 Copay
Tier 3	$175 Copay

	Monthly Rates
Employee Only	$235.20
Employee + Spouse	$623.84
Employee + Child(ren)	$529.52
Family	$870.16

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Summary of Benefits

Medical Benefit Summary

Nayya Employee Choose

	In-Network
Deductible (Individual/Family)	$2,500/$5,000
Member Coinsurance	0%
Out-of-Pocket Max (Individual/Family)	$2,500/$5,000
Primary Care	$0 Spira; otherwise Deductible
Specialist Visit	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	$182.63
Employee + Spouse	$511.65
Employee + Child(ren)	$428.19
Family	$720.07

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Summary of Benefits

Medical Benefit Summary

Nayya Employee Choose

	In-Network
Deductible (Individual/Family)	$3,500/$7,000
Member Coinsurance	0%
Out-of-Pocket Max (Individual/Family)	$3,500/$7,000
Primary Care	$0 Spira; otherwise Deductible
Specialist Visit	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	$125.56
Employee + Spouse	$389.94
Employee + Child(ren)	$318.21
Family	$557.18

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Summary of Benefits

Medical Benefit Summary

Nayya Employee Choose

	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
Primary Care Visit	Deductible	Deductible
Specialist Visit	Deductible	Deductible
Urgent Care	Deductible	Deductible
Emergency Room	Deductible	Deductible

Prescription Drugs	In-Network	Out-of-Network
Retail	Deductible	N/A
Mail Order	Deductible	N/A

	Monthly Rate
Employee Only	$170.16
Employee + Spouse	$485.08
Employee + Child(ren)	$404.16
Employee + Family	$684.47

Downloads

Summary of Benefits

Medical Benefit Summary

Nayya Employee Choose

Provided By

Blue Cross and Blue Shield of Kansas City

Provider Website

https://bluekc.com

Customer Service

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