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Blue - Saver PCB Gold
Kansas, 2017
Plan Type
PPO
Metal Tier
Gold
Out of Pocket Maximum
$3,000
Deductible
$1,500
Emergency Room Care: 10% Coinsurance after deductible
Cost Sharing Benefits (In Network)
Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.
| Deductible (Individual) | $1,500 |
|---|---|
| Deductible (Family) | $3,000 |
| Coinsurance | Not applicable |
| Out of Pocket Maximum (Individual) | $3,000 |
| Out of Pocket Maximum (Family) | $6,000 |
Doctor Visits
| Primary Care Visit | 10% Coinsurance after deductible |
|---|---|
| Specialist Visit | 10% Coinsurance after deductible |
| Inpatient Facility | 10% Coinsurance after deductible |
| Inpatient Physician | 10% Coinsurance after deductible |
| Emergency Room Services | 10% Coinsurance after deductible |
Tests and Imaging
| Imaging (CT/PET Scans, MRIs) | 10% Coinsurance after deductible |
|---|---|
| Laboratory Outpatient and Professional Services | 10% Coinsurance after deductible |
| X-Ray and Diagnostic Imaging | 10% Coinsurance after deductible |
Health Management Programs
| Asthma | Available |
|---|---|
| Depression | Available |
| Diabetes | Available |
| Heart Disease | Available |
| High Blood Pressure / High Cholesterol | Available |
| Lower Back Pain | Not available |
| Pain Management | Not available |
| Pregnancy | Available |
| Weight Loss | Not available |
Other
| Mental / Behavioral Health Inpatient | 10% Coinsurance after deductible |
|---|---|
| Mental / Behavioral Health Outpatient | 10% Coinsurance after deductible |
| Rehabilitative Speech Therapy | 10% Coinsurance after deductible |
| Rehabilitative Occupational & Physical Therapy | 10% Coinsurance after deductible |
| Outpatient Facility | 10% Coinsurance after deductible |
| Outpatient Surgery | 10% Coinsurance after deductible |
Prescription Drugs
| Generic Rx | $10 Copay after deductible |
|---|---|
| Preferred Brand Rx | $55 Copay after deductible |
| Non Preferred Brand Rx | 20% Coinsurance after deductible |
| Specialty Drugs | 30% Coinsurance after deductible |
Other Plans in Kansas
| Plan | Deductible | Coinsurance | Out of Pocket |
|---|---|---|---|
| Plan First PCB Bronze | Deductible $6,900 | Coinsurance Not applicable | Out of Pocket $7,150 |
| Plan First Select Bronze | Deductible $6,900 | Coinsurance Not applicable | Out of Pocket $7,150 |
| Plan Basic Select Silver | Deductible $3,500 | Coinsurance Not applicable | Out of Pocket $5,000 |
| Plan Saver PCB Bronze | Deductible $5,500 | Coinsurance Not applicable | Out of Pocket $6,550 |
| Plan Standard PCB Silver | Deductible $3,500 | Coinsurance Not applicable | Out of Pocket $7,150 |
| Plan Standard PCB Bronze | Deductible $6,650 | Coinsurance Not applicable | Out of Pocket $7,150 |
| Plan Saver PCB Silver | Deductible $3,000 | Coinsurance Not applicable | Out of Pocket $5,000 |
| Plan First Select Silver | Deductible $5,000 | Coinsurance Not applicable | Out of Pocket $6,000 |
| Plan Basic Select Bronze | Deductible $6,350 | Coinsurance Not applicable | Out of Pocket $7,150 |
| Plan Saver Select Gold | Deductible $1,500 | Coinsurance Not applicable | Out of Pocket $3,000 |