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Medical Plan

Group Number

Network

Carrier Website

Customer Service Number

877.337.7472

bluekc.com

Preferred Care Blue

BCBS.png
OPTION 3 - $1,500 DEDUCTIBLE
In-Network
Medical Networks
Preferred Care Blue
Deductible
$1,500 individual / $3,000 family
Coinsurance
100%
Out-of-pocket maximum
$6,500 individual / $13,000 family
Physician office visit
$40 Copay
Specialty office visit
$100 Copay
Prescription drugs Tier 1 / Tier2 / Tier 3
$10 / $45 / $90 / 25% Copay
Mail order drug program Tier 1 / Tier 2 / Tier 3
$25 / $112.50 / $225 Copay
Routine preventative care
No charge
Inpatient hospital service / Outpatient surgery
Deductible
Emergency room (copay waived if admitted)
Deductible
Urgent care
$100 Copay
MRI, MRA, CT and PET scans
Deductible
Lab services
Deductible
X-rays
Deductible
Lifetime maximum
Unlimited

SBC

Find a provider

To obtain a list of providers participating in your BlueKC network simply go to www.mybluekc.com or call 888.989.8842

47737000

This summary of benefits is intended only to highlight your benefits and should not be relied upon to fully determine coverage.  Please refer to the summary of Benefits and Coverage (SBC) for a complete listing of services, limitations, exclusions and a description of all terms and conditions of coverage.  Where there is a discrepancy, the SBC will prevail.

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