Blue Cross and Blue Shield of Kansas City

Blue KC First Bronze Preferred-Care Blue EPO

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Combined Medical and Drug Deductible	Individual: $7,000.00 Family: $14000 Per Person: $7000
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200.00 Family: $18400 Per Person: $9200

Primary Doctor

CoPay: $40.00
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: You have a $0 copay for telehealth visits with your doctor, saving you money and time. This Plan offers first dollar coverage for the first four (4) office visits. Eligible services include primary care, specialist, urgent care, mental health, and/or substance abuse services received in an office. Deductible and coinsurance apply after you have received four (4) visits in the calendar year. Office visits are subject to the applicable copayment, see Plan Documents for more information.

Specialist

CoPay: $40.00
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: You have a $0 copay for telehealth visits with your doctor, saving you money and time. This Plan offers first dollar coverage for the first four (4) office visits. Eligible services include primary care, specialist, urgent care, mental health, and/or substance abuse services received in an office. Deductible and coinsurance apply after you have received four (4) visits in the calendar year. Office visits are subject to the applicable copayment, see Plan Documents for more information.

Preferred Brand Drugs	CoPay: $125.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $325.00 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

Hospital Services	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Emergency Room

Urgent Care Facility

CoPay: $40.00
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Save money and time with Blue KC Virtual Care. You may access virtual care for a $0 copay, 24/7. This Plan offers first dollar coverage for the first four (4) office visits. Eligible services include primary care, specialist, urgent care, mental health, and/or substance abuse services received in an office. Deductible and coinsurance apply after you have received four (4) visits in the calendar year. Office visits are subject to the applicable copayment, see Plan Documents for more information.

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Routine Eye Exams for Children

Routine Dental Checkups for Children