Medical Benefits

Pharmacy Information

RxBIN#: 021825
PCN#: IRX
Rx Group#: BLUEKC
Specialty Pharmacy: OptumRx Home Delivery at 1-844-579-7774

Preferred Care Blue Network PPO Plan	In-Network
Deductible (Individual/Family)	$3,400/$6,800
Member Coinsurance	0%
Out-of-Pocket Max (Individual/Family)	$3,400/$6,800
Physician Visits
Primary Care Visit	Deductible
Specialist Visit	Deductible
Routine Preventive	Covered at 100%
Hospital Services
Inpatient Hospital Care	Deductible
Outpatient Hospital Care	Deductible
Urgent Care Visit	Deductible
Emergency Care Visit	Deductible
Prescription Benefits
Retail	Deductible
Mail Order	Deductible

Monthly Employee Rates
Employee Only	$75
Employee + Spouse	$630
Employee + Child(ren)	$630
Employee + Family	$765

Monthly Employer HSA Contributions
Employee Only	$50
Employee + Spouse	$100
Employee + Child(ren)	$100
Employee + Family	$100

Downloads

Summary of Benefits and Coverage

Virtual Care

Over the Counter Covid Test Reimbursement Form

Creditable Coverage Notice

Pharmacy Information

RxBIN#: 021825
PCN#: IRX
Rx Group#: BLUEKC
Specialty Pharmacy: OptumRx Home Delivery at 1-844-579-7774

Blue Select Plus Network Narrow Network Plan	In-Network
Deductible (Individual/Family)	$3,400/$6,800
Member Coinsurance	0%
Out-of-Pocket Max (Individual/Family)	$3,300/$6,600
Physician Visits
Primary Care Visit	Deductible
Specialist Visit	Deductible
Preventive Care	Covered at 100%
Hospital Services
Inpatient Hospital Care	Deductible
Outpatient Hospital Care	Deductible
Urgent Care	Deductible
Emergency Room	Deductible
Prescription Benefits
Retail	Deductible
Mail Order	Deductible

Monthly Employee Rates
Employee Only	$65
Employee + Spouse	$530
Employee + Child(ren)	$530
Employee + Family	$660

Monthly Employer HSA Contributions
Employee Only	$50
Employee + Spouse	$100
Employee + Child(ren)	$100
Employee + Family	$100

Downloads

Summary of Benefits and Coverage

Virtual Care

Over the Counter Covid Test Reimbursement Form

Creditable Coverage Notice

BlueSelectPlus Member 100+

This plan is available only to employees who live or work in the Kansas City Metro Area. It is a narrow-network medical plan and offers only in-network coverage, except for emergency care.

In-network facilities include Spira Care Centers and BlueSelect Plus providers and hospitals. To find an in-network doctor, please visit www.spiracare.com.

Pharmacy Information

RxBIN#: 021825
PCN#: IRX
Rx Group#: BLUEKC
Specialty Pharmacy: OptumRx Home Delivery at 1-844-579-7774

Spira Care Network	Spira Care Centers
Deductible (Individual/Family)	$660
Member Coinsurance	0%
Out-of-Pocket Max(Individual/Family)	$3,400/$6,800
Physician Visits
Primary Care Visit	Deductible
Specialist Visit	Deductible*
Routine Preventive Care	Covered at 100%
Hospital Services
Inpatient Hospital Care	Deductible*
Outpatient Hospital Care	Deductible*
Urgent Care	Deductible
Emergency Room	Deductible*
Prescription Benefits
Retail	Deductible
Mail Order	Deductible
*Services not available at Spira Care Centers, but are accessible at other providers and facilities within the Blue Select Plus network.