Benefit Explanation: This Plan offers $0 copay to Spira Care for your doctor's visit, counseling, and any associated lab or x-rays prescribed by a Spira Care physician. You have a $0 copay for telehealth visits with your doctor, saving you money and time.
Specialist
CoPay: $100.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: You have a $0 copay for telehealth visits with your doctor, saving you money and time.
Prescription Drug Information
Preferred Brand Drugs
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Non Preferred Brand Drugs
CoPay: $250.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Generic Drugs
CoPay: $5.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: See the Prescription Drug formulary for more information on drug costs.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Urgent Care Facility
CoPay: $100.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Save money and time with Blue KC Virtual Care. You may access virtual care for a $0 copay, 24/7.
1-817-813-4562, TTY 711
