Traditional Plan

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, Creekwood & Briarcliff Surgery Centers

Preferred Care Blue In-Network Providers

Out of Network Providers

LIFETIME MAXIMUMUnlimited
ANNUAL DEDUCTIBLE
    Individual
$0$550$
    Family
$0$1,375 $2,125
ANNUAL COINSURANCE10%20% Physician services
30% Facility services
75%
OUT OF POCKET MAXIMUUM
    Medical Plan
    Individual
$4,550 $4,550 No Out of Pocket Max for an Out of Network Provider
    Family
$9,750 $9,750
PHYSICIAN/OFFICE VISITS
      Physician Office Visit
$30 copayDeductible, $30 copay then 20% of the Allowable ChargeDeductible, $30 copay then 75% of the Allowable Charge
      Specialist
$40 copayDeductible, $40 copay then 20% of the Allowable Charge (including Quick Care/Minute Clinics)Deductible, $40 copay then 75% of the Allowable Charge
(applies to Gashland Urgent Care & Meritas Express Care)
    Physical Services in the Office
Deductible then 10% of the Allowable ChargeDeductible then 20% of the Allowable ChargeDeductible then 75% of the Allowable Charge
    Emergency Room Visits
Deductible, $200 copay then 25% of the Allowable ChargeDeductible, $200 copay then 25% of the Allowable ChargeDeductible, $200 Copay 25% of the allowable
The Blue Card Program National Network for out of area 1-800-810-2583
(copay waived if admitted)
    Emergency Room Physician Services
Deductible then 10% of PPO Allowable ChargeDeductible then 10% of PPO Allowable ChargeDeductible then 10% of the Allowable Charge
    Inpatient Services- Hospital charges for Room & Board related to Admissions
No Deductible, $250 copay per day up to out of pockeet max, then 10% coinsuranceDeductible then 30% of the Allowable Charges Pre-cert is requiredDeductible then 75% of the Allowable Charges Pre-cert is required
    Observation care (23+ hours)
No deductible. Pre-cert required. $250 copay per day up to out of pocket max. 10% coinsuranceDeductible then 30% of the Allowable Charges Pre-cert is requiredDeductible then 75% of the Allowable Charges Pre-cert is required
    Physician Hospital Visits
No Deductible, 10% of the Allowable ChargeDeductible, 20% of the Allowable ChargeDeductible, 75% of the Allowable Charge
No Deductible, $250 copay, then 10% of the Allowable ChargeDeductible, 30% of the Allowable ChargeDeductible, 75% of the Allowable Charge
    Ambulance Including air ambulance
No Deductible, 10% of the PPO Allowable ChargesDeductible, 20% of the PPO Allowable ChargePPO Benefit Year Deductible then 20% of the Billed Charges up to PPO out of pocket max
BI-WEEKLY PREMIUMS
    Employee (EE)
$40.06
    EE + Child(ren)
$85.25
    EE + Spouse
$96.88
    Family
$139.41

Preventative Drug Info

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Provider Choice

North Kansas City Hospital Outpatient Pharmacy

MedTrak Participating Pharmacies

Prescription plan deductible per calendar yearNo 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 drugsYou pay 20% coinsurance; only covered at the NKCH retail pharmacyNot 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.
Over-the-counter preventative medicationsAspirin, 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 deterrentsCovered in full; limited to two treatment cycles per year. Over-the-counter, generic, and brand smoking deterrents; requires written prescription from the physician.
ContraceptivesCovered in full: Hormonal, Barrier, Emergency, Implants; includes Generic and over-the-counter products; requires written prescription from the physician