North Kansas City Hospital offers you and your dependents health insurance through BlueCross BlueShield South Carolina.You may review the features and benefits of the Traditional Plan below.
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Medical Information
North Kansas City Hospital, Meritas Physician Clinics & Gashland | Blue Select Plus In-Network Providers” | Out of Network Providers |
|
|---|---|---|---|
| LIFETIME MAXIMUM | Unlimited | ||
| ANNUAL DEDUCTIBLE | |||
| $0 | $1,000 | $4,000 |
| $0 | $2,500 | $8,000 |
| ANNUAL COINSURANCE | 10% | 20% Physician services 30% Facility services | 75% |
| OUT OF POCKET MAXIMUUM | |||
|
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| $4,750 | $4,750 | No Out of Pocket Max for an Out of Network Provider |
| $9,500 | $9,500 | |
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| $2,150 | $2,150 | No Out of Pocket Max for an Out of Network Provider |
| $4,300 | $4,300 | |
| PHYSICIAN/OFFICE VISITS | |||
| $30 copay $10 copay Meritas Health Express (sick visits only) | Deductible, $30 copay then 20% of the Allowable Charge | Deductible, $30 copay then 75% of the Allowable Charge |
| $50 copay (includes Gashland urgent care and sports/camp physicals at Meritas Health Express) | $50 copay, then deductible | $50 copay, then deductible |
| Deductible then 10% of the Allowable Charge | Deductible then 20% of the Allowable Charge | Deductible then 75% of the Allowable Charge |
(copay waived if admitted) | $500 copay then deductible | $500 copay then deductible | $500 copay then deductible |
| Not available at NKCH | Deductible then 20% of PPO Allowable Charge | Deductible then 20% of the Allowable Charge |
| $500 copay per day | Deductible then 30% of the Allowable Charges Pre-cert is required | Deductible then 75% of the Allowable Charges Pre-cert is required |
| $500 copay | Deductible then 30% of the Allowable Charges Pre-cert is required | Deductible then 75% of the Allowable Charges Pre-cert is required |
| No Deductible, 10% of the Allowable Charge | Deductible, 20% of the Allowable Charge | Deductible, 75% of the Allowable Charge |
| No Deductible, $300 Copay | Deductible, 30% of the Allowable Charge | Deductible, 75% of the Allowable Charge |
| No Deductible, 10% of the PPO Allowable Charges | Deductible, 20% of the PPO Allowable Charge | PPO Benefit Year Deductible then 20% of the Billed Charges up to PPO out of pocket max |
| BI-WEEKLY PREMIUMS | |||
| $45.58 | ||
| $99.19 | ||
| $112.60 | ||
| $169.46 | ||
Preventative Drug Info
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- Prescription Plan Summary
- Medtrak – Performance 90 Pharmacy Network
- Medtrak – Preferred Pharmacy Network
- SpecialtyPlus Medication List
- Generic Incentive Program
- Prescription Drug Plan Summary
- The Affordable Care Act (ACA) requirements that apply to medications dispensed pursuant to a writtenprescription and subject to FDA guidelines.
Provider Choice | North Kansas City Hospital Outpatient Pharmacy | MedTrak Participating Pharmacies |
|---|---|---|
| Prescription plan deductible per calendar year | No deductible for prescriptions filled at NKCH Outpatient Pharmacy | $100 per person up to $250 per family |
| Generic prescriptions | $4 copay per 30-day supply $8 copay per 90-day supply | $12 copay per 30-day supply $36 copay per 90-day supply |
| Brand name prescriptions with no available generic substitute | $50 copay per 30-day supply $100 copay per 90-day supply | $65 copay per 30-day supply $195 copay per 90-day supply |
| Brand name with generic substitute | $80 copay per 30-day supply plus the difference in cost between the brand prescription and generic equivalent $160 copay per 90-day supply plus the difference in cost between the brand prescription and generic equivalent | $90 copay per 30-day supply plus the difference in cost between the brand prescription and generic equivalent $270 copay per 90-day supply plus the difference in cost between the brand prescription and generic equivalent |
| Specialty drugs | You pay 20% coinsurance; only covered at the NKCH retail pharmacy | Not Covered |
| Rx out-of-pocket maximum | Individual: $2,150 Family: $4,300 This maximum combines with the medical plan out-of-pocket maximum not to exceed $7,150/individual & $14,300/family. |
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| Over-the-counter preventative medications | Aspirin, Fluoride Supplements, Folic Acid, Iron Supplements, Breast Cancer Prevention; Covered in Full; from an In-Network Retail Pharmacy, not subject to calendar year deductible. Requires written prescription from the physician. Breast Cancer prevention for ages 35 or older; OTC and legend generics | |
| Smoking deterrents | Covered in full; limited to two treatment cycles per year. Over-the-counter, generic, and brand smoking deterrents; requires written prescription from the physician. | |
| Contraceptives | Covered in full: Hormonal, Barrier, Emergency, Implants; includes Generic and over-the-counter products; requires written prescription from the physician | |
