2 / 12
P A G E 2
B E N E F I T O V E R V I E W
Medical and Prescription Drug Benefits
Current
Plan Design
Anthem
Anthem
Anthem
KC 30
KC 25
KC 25 Plus
National
National
National
In-Network
Out-of-Network
In-Network
Out-of-
Network
In-Network
Out-of-
Network
Deductible:
- Single
$1,000
$1,500
$500
$750
No deductible
$1,000
- Family
$2,000
$3,000
$1,000
$1,500
No deductible
$2,000
Out of Pocket Maximum:
(Medical/RX)
- Single
$4,500
$6,250
$4,000
$5,500
$4,500
$5,500
- Family
$9,000
$12,500
$8,000
$11,000
$9,000
$11,000
Coinsurance:
80%
60%
80%
60%
80%
70%
Office Visits:
- Preventive Care - Children
(0-17 years)
Covered in full
Ded, then 40%
Covered in
full
40% after ded
Covered in
full
30% after ded
- Preventive Care Adult
Covered in full
Ded, then 40%
Covered in
full
40% after ded
Covered in
full
30% after ded
- Primary Care Physician (PCP)
$30 copay
Ded, then 40%
$25 copay 40% after ded $25 copay 30% after ded
- Specialist
$50 copay
Ded, then 40%
$50 copay 40% after ded $50 copay 30% after ded
- Lab and x-rays
20% after ded
Ded, then 40%
20% after ded 40% after ded
Covered in
full
30% after ded
Hospitalization:
- Inpatient
20% after ded
Ded, then 40%
20% after ded 40% after ded
$350
per day
30% after ded
- Outpatient
20% after ded
Ded, then 40%
20% after ded 40% after ded $300 copay 30% after ded
- Urgent Care
$30 copay
Ded, then 40%
$25 copay 40% after ded $25 copay 30% after ded
- Emergency Room (waived if
admitted)
20% after ded Same as In Network 20% after ded 40% after ded $250 copay 30% after ded
Prescription Drugs:
- Deductible
- Generic
$10 copay
$10 copay
$10 copay
- Brand
$30 copay
$30 copay
$30 copay
- Brand Non-Formulary
$50 copay
$50 copay
$50 copay
- Speciality Drugs
20% coinsurance up to $200
20% coinsurance up to $200 20% coinsurance up to $200
Mail Order
$25/$75/$125/20% coinsurance up to $200
Semi Monthly Pay Deductions
KC 30
Employee
$291.47
Employee + Child
$398.15
Employee + Children
$592.56
Employee + Spouse
$652.89
Employee + Family
$899.18
Semi Monthly Pay Deductions
KC 25
Employee
$308.00
Employee + Child
$420.73
Employee + Children
$626.29
Employee + Spouse
$689.91
Employee + Family
$950.18
Semi Monthly Pay Deductions
KC 25 Plus
Employee
$324.53
Employee + Child
$443.31
Employee + Children
$659.77
Employee + Spouse
$726.95
Employee + Family
$1001.17