Blue Cross Blue Shield of Kansas Benefits Plan Options

Current Triple Option Plan  Deductible  Option 1: $500/$1000  Option 2: $1000/$2000  Option 3: $1500/$3000  Coinsurance - $1000/$2000 (80/20%)  Office Visit Copay - $20 no limits  Accident Coverage – Subject to deductible / coinsurance  Prescription Drugs - $15/30/45 copay, Mail order $37.50/75/ Employee Premium Option Option Option Option Option Option Employee$0.32$238.57$0$215.00$0$ Emp / Child(ren) $178.10$680.26$149.54$631.60$127.46$ Emp/Spouse$431.02$943.23$400.87$892.56$377.55$ Emp / Dependents $608.80$ $564.12$ $529.57$

High Deductible Health Plan 1 (HDHP)  Deductible - $2500/$5000  Coinsurance - $0  Office Visit Copay – Subject to deductible / coinsurance  Accident Coverage – Subject to deductible / coinsurance  Prescription Drugs – Subject to deductible/coinsurance, then $15/50/75 copay, Mail order $37.50/125/ Employee Premium EmployeeEmp/Child(ren)Emp/SpouseEmployee / Dependents $133.98$470.00$718.35$

AffordaBlue Triple Option  Deductible  Option 1: $500/$1500  Option 2: $1000/$3000  Option 3: $2000/$6000  Coinsurance - $1000/$3000 (80/20%)  Office Visit Copay - $25, limited to 5 visits per person, 15 per family  Accident Coverage – $50 copay for initial visit  Prescription Drugs - $100 / $300 deductible, then 50% Employee Premium Option 1Option 2Option 3 Employee$171.97$144.77$ Emp/Child(ren)$527.60$467.67$ Emp/Spouse$800.01$741.53$ Emp/Dependents$ $ $912.98

High Deductible Health Plan 2 (HDHP)  Deductible - $3000/$6000  Coinsurance - $0  Office Visit Copay – Subject to deductible / coinsurance  Accident Coverage – Subject to deductible / coinsurance  Prescription Drugs – Subject to deductible/coinsurance, then $15/50/75 copay, Mail order $37.50/125/ Employee Premium EmployeeEmp/Child(ren)Emp/SpouseEmployee / Dependents $110.83$422.21$668.58$979.97

Comprehensive Major Medical  Deductible - $1500/3000  Coinsurance - $2000/$4000 (60/40%)  Office Visit Copay - $30 Primary Care (PCP) or $60 Specialist, limited to 5 visit per person / 15 family  Accident Coverage – Pays 100% up to $1000 per person, then subject to deductible/coinsurance  Prescription Drugs - $15/50/75/150 copay, Mail order $37.50/125/187.50/375 Employee Premium EmployeeEmp/Child(ren)Emp/SpouseEmployee / Dependents $100.38$396.28$646.11$942.02

High Deductible Health Plan 3 (HDHP)  Deductible - $5000/$10,000  Coinsurance - $0  Office Visit Copay – Subject to deductible / coinsurance  Accident Coverage – Subject to deductible / coinsurance  Prescription Drugs – Subject to deductible/coinsurance, then $15/50/75 copay, Mail order $37.50/125/ Employee Premium EmployeeEmp/Child(ren)Emp/SpouseEmployee / Dependents $34.15$263.89$503.72$733.46

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