High Deductible 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 High Deductible 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 MAXIMUMUnlimited
ANNUAL DEDUCTIBLE
    Individual
$500$2,750$6,600
    Family
$1,000$5,500 $13,200
ANNUAL COINSURANCE10%20% Physician services
30% Facility services
75%
OUT OF POCKET MAXIMUUM
    Medical Plan
      Individual
$5,000 $5,000 No Out of Pocket Max for an Out of Network Provider
      Family
$10,000 $10,000
    RX Plan
      Individual
$2,150$2,150No Out of Pocket Max for an Out of Network Provider
      Family
$4,300$4,300
PHYSICIAN/OFFICE VISITS
      Primary Care
$30 copay + deductible
$10 copay + deductible
Meritas Health Express (sick visits only)
Deductible, $30 copay then 20% of the Allowable ChargeDeductible, $30 copay then 75% of the Allowable Charge
      Specialist
$50 copay + deductible (includes Gashland Urgent Care and sports/camp physicals at Meritas Health Express)Deductible, then
$50 copay then coinsurance
Deductible, then
$50 copay then coinsurance
    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
    (copay waived if admitted)
$500 copay then deductible$500 copay then deductible$500 copay then deductible
    Emergency Room Physician Services
Not available at NKCHDeductible then 20% of PPO Allowable ChargeDeductible then 20% of the Allowable Charge
    Inpatient Services- Hospital charges for Room & Board related to Admissions
$500 copay per day + deductibleDeductible then 30% of the Allowable Charges Pre-cert is requiredDeductible then 75% of the Allowable Charges Pre-cert is required
    Observation care (23+ hours)
$500 copay + deductibleDeductible 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
    Outpatient Surgery
No Deductible, $300 CopayDeductible, 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)
$27.14
    EE + Child(ren)
$81.42
    EE + Spouse
$62.76
    Family
$108.93

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