BCBSKC $4,000 HDHP 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 2022 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)
$4,000 individual /
$8,000 family
$1,500 individual /
$3,000 family
Out-of-Pocket Maximum
(Calendar year)
$5,000 individual /
$10,000 family
$6,000 individual /
$12,000 family
Coinsurance
(Plan pays/You pay)
90% / 10%60% / 40%
Primary Care Physician Office VisitsDeductible, then 10% coinsuranceDeductible, then 30% coinsurance
Specialist Office VisitsDeductible, then 10% coinsuranceDeductible, then 30% coinsurance
Preventive Care100%Deductible, then 30% coinsurance
Urgent CareDeductible, then 10% coinsuranceDeductible, then 30% coinsurance
Emergency RoomIn-Network deductible, then 10% coinsurance
Inpatient ServicesDeductible, then 10% coinsuranceDeductible, then 30% coinsurance
Outpatient ServicesDeductible, then 10% coinsuranceDeductible, then 30% coinsurance
Retail Prescription Drug Coverage
(up to 34-day supply)
Deductible, then
Tier 1: $10 copay
Tier 2: $35 copay
Tier 3: $60 copay
Deductible, then 50% coinsurance
Mail Order
(up to 102-day supply)
Deductible, then
Tier 1: $25 copay
Tier 2: $87.50 copay
Tier 3: $150 copay
Deductible, then 50% coinsurance
Monthly Premium
$4,000 HDHP
Preferred-Care Blue
    Employee only
$23.49
    Employee + Spouse
$309.05
    Employee + Child(ren)
$279.62
    Family
$426.81

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