BCBSKC $750 PPO Deductible Plan
(Preferred-Care Blue)

nbkc is committed to providing quality health coverage for you and your dependents. Blue KC will continue to provide our Medical and Prescription Drug coverage for the 2021 plan year. For claim inquiries, help finding a provider, or general questions, please contact Blue KC at 816-395-3558 or visit MyBlueKC.com.

The chart below provides a high-level look at the amounts you pay when visiting in-network and out-of-network providers. Please refer to full plan descriptions for greater detail, in order to make the Medical/Rx choice that best meets the needs for you and your family.

Plan Features
In-Network
Out-of-Network
Deductible
(Calendar year)
$750 individual /
$1,500 family
$1,500 individual /
$3,000 family
Out-of-Pocket Maximum
(Calendar year)
$3,000 individual /
$6,000 family
$6,000 individual /
$12,000 family
Coinsurance
(Plan pays/You pay)
80% / 20%60% / 40%
Primary Care Physician Office Visits$25 copayDeductible, then 40% coinsurance
Specialist Office Visits$50 copayDeductible, then 40% coinsurance
Preventive Care100%Deductible, then 40% coinsurance
Urgent Care$50 copayDeductible, then 40% coinsurance
Emergency Room$300 Copay, then deductible, then 20% coinsurance
Inpatient ServicesDeductible, then 20% coinsuranceDeductible, then 40% coinsurance
Outpatient Services$1,500 individual /
$3,000 family
Deductible, then 40% coinsurance
Retail Prescription Drug Coverage
(up to 34-day supply)
Tier 1: $10 copay
Tier 2: $35 copay
Tier 3: $60 copay
Copay + 50% coinsurance
Mail Order
(up to 102-day supply)
Tier 1: $25 copay
Tier 2: $87.50 copay
Tier 3: $150 copay
Copay + 50% coinsurance
Monthly Premium
$750 PPO
Preferred-Care Blue
    Employee only
$129.42
    Employee + Spouse
$508.11
    Employee + Child(ren)
$459.71
    Family
$701.68

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