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Bonner Springs/Edwardsville USD 204
Throug
h www.bluekc.comyou will
have the ability to:
Find Doctors & Hospitals
Check Claim Status
Order New ID Card
Print Temporary ID Card
View Benefits
Access BCBSKC Drug List
Medical Plan
Bonner Springs/Edwardsville USD 204 offers five medical plan options for
you to choose from. The benefits you elect now will be effective
September 1, 2017 – December 31, 2017.
When reviewing your plan options, please be sure to pay close attention to
the provider network associated with each plan.
This Medical Plan table is for illustrative purposes only and does not include all benefits, plan limitations, and/or
exclusions. This represents in-network benefits only. Please refer to the certificate of coverage BCBS summary for
greater detail. In the event there is a discrepancy in benefits, the carrier benefit summary/SPD will always govern.
QHDHP #1
QHDHP #2
Base PPO
HMO
Buy-Up PPO
Preferred Care
Blue
Blue Select Plus
Preferred-Care
Blue
Blue Care
Preferred-Care
Blue
Deductible
- Individual
- Family
$2,600
$5,200
$2,600
$5,200
$1,000
$2,000
None
None
$500
$1,000
Coinsurance
0%
0%
20%
0%
20%
Out of Pocket Max
- Individual
- Family
$2,600
$5,200
$2,600
$5,200
$4,000
$8,000
$3,000
$7,500
$2,750
$5,500
Physician Office Visits
- PCP
- Specialist
-Chiropractic
Subject to Ded.
Subject to Ded.
Subject to Ded.
Subject to Ded.
Subject to Ded.
Subject to Ded.
$40
$80
Ded. then 20%
$40
$80
$40
$20
$40
Ded. then 20%
Hospital Services
- Inpatient
- Outpatient surgical
- Hi-Tech Scans
Subject to Ded.
Subject to Ded.
Subject to Ded.
Subject to Ded.
Subject to Ded.
Subject to Ded.
Ded. then 20%
Ded. then 20%
Ded. then 20%
$500 per day up to
$2,500/ calendar
year/person
Ded. then 20%
Ded. then 20%
Ded. then 20%
Emergency Room
Urgent Care
Subject to Ded.
Subject to Ded.
Subject to Ded.
Subject to Ded.
$200 then Ded.
then 20%
$80
$200
$80
150 then Ded.
then 20%
$40
Prescription Drugs
- Deductible
- Tier 1 Generic
- Tier 2 Preferred
- Tier 3 Non-Preferred
- Mail order (120 day)
Medical Ded. then:
$0
$0
$0
$0
Medical Ded. then:
$0
$0
$0
$0
N/A
$12
$35
$60
$24/$70/$120
N/A
$12
$35
$60
$24/$70/$120
N/A
$12
$35
$60
$24/$70/$120