2017 Traditional Plan | 2017 High Deductible Plan |
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|---|---|---|---|---|---|---|
| PROVIDER CHOICE | North Kansas City Hospital, Meritas Physician Clinics, Gashland, Creekwood & Briarcliff Surgery Centers | Preferred Care Blue In-Network Providers | Out of Network Providers | North Kansas City Hospital, Meritas Physician Clinics, Gashland, Creekwood & Briarcliff Surgery Centers | Preferred Care Blue In-Network Providers | Out of Network Providers |
| LIFETIME MAXIMUM | Unlimited | |||||
| ANNUAL DEDUCTIBLE | ||||||
| $0 | $550 | $ | $0 | $2,000 | $3,000 |
| $0 | $1,375 | $2,125 | $0 | $5,000 | $7,500 |
| ANNUAL COINSURANCE | 10% | 20% Physician services 30% Facility services | 75% | 10% | 20% Physician services 30% Facility services | 75% |
| OUT OF POCKET MAXIMUUM | ||||||
|
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| $4,550 | $4,550 | No Out of Pocket Max for an Out of Network Provider | $5,000 | $5,000 | No Out of Pocket Max for an Out of Network Provider |
| $9,750 | $9,750 | $10,000 | $10,000 | ||
| PHYSICIAN/OFFICE VISITS | ||||||
| $30 copay | Deductible, $30 copay then 20% of the Allowable Charge | Deductible, $30 copay then 75% of the Allowable Charge | $30 copay | Deductible, $30 copay then 20% of the Allowable Charge | Deductible, $30 copay then 75% of the Allowable Charge |
| $40 copay (applies to Gashland Urgent Care & Meritas Express Care) | Deductible, $40 copay then 20% of the Allowable Charge (including Quick Care/Minute Clinics) | Deductible, $40 copay then 75% of the Allowable Charge | $40 copay (applies to Gashland Urgent Care & Meritas Express Care) | Deductible, $40 copay then 20% of the Allowable Charge (including Quick Care/Minute Clinics) | Deductible, $40 copay then 75% of the Allowable Charge |
| Deductible then 10% of the Allowable Charge | Deductible then 20% of the Allowable Charge | Deductible then 75% of the Allowable Charge | 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) | Deductible, $200 copay then 25% of the Allowable Charge | Deductible, $200 copay then 25% of the Allowable Charge | Deductible, $200 Copay 25% of the allowable The Blue Card Program National Network for out of area 1-800-810-2583 | Deductible, $200 copay then 25% of the Allowable Charge | Deductible, $200 copay then 25% of the Allowable Charge | Deductible, $200 Copay 25% of the allowable The Blue Card Program National Network for out of area 1-800-810-2583 |
| Deductible then 10% of PPO Allowable Charge | Deductible then 10% of PPO Allowable Charge | Deductible then 10% of the Allowable Charge | Deductible then 10% of PPO Allowable Charge | Deductible then 10% of PPO Allowable Charge | Deductible then 10% of the Allowable Charge |
| No Deductible, $250 copay per day up to out of pockeet max, then 10% coinsurance | Deductible then 30% of the Allowable Charges Pre-cert is required | Deductible then 75% of the Allowable Charges Pre-cert is required | No Deductible, $250 copay per day up to out of pockeet max, then 10% coinsurance | Deductible then 30% of the Allowable Charges Pre-cert is required | Deductible then 75% of the Allowable Charges Pre-cert is required |
| No deductible. Pre-cert required. $250 copay per day up to out of pocket max. 10% coinsurance | Deductible then 30% of the Allowable Charges Pre-cert is required | Deductible then 75% of the Allowable Charges Pre-cert is required | No deductible. Pre-cert required. $250 copay per day up to out of pocket max. 10% coinsurance | 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, 10% of the Allowable Charge | Deductible, 20% of the Allowable Charge | Deductible, 75% of the Allowable Charge |
| No Deductible, $250 copay, then 10% of the Allowable Charge | Deductible, 30% of the Allowable Charge | Deductible, 75% of the Allowable Charge | No Deductible, $250 copay, then 10% of the Allowable Charge | 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 | 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 | ||||||
| $40.06 | $24.76 | ||||
| $85.25 | $54.48 | ||||
| $96.88 | $74.29 | ||||
| $139.41 | $89.77 | ||||
Prescription Plan Comparison
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. |
|
| 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 | |