Blue KC Standard Gold Preferred-Care Blue EPO - 34762MO0590013 Health Insurance Plan

Blue Cross and Blue Shield of Kansas City health insurance plan with the Plan ID 34762MO0590013. The plan is called Blue KC Standard Gold Preferred-Care Blue EPO.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.94% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 34762MO0590013
Health Insurance Plan Year 2025
State Missouri
Health Insurance Issuer Blue Cross and Blue Shield of Kansas City
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 34762MO0590013-00
Provider Network(s) NETWORK PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT).

Providers Missouri All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 34762MO0590013-00

Standard On Exchange Plan - 34762MO0590013-01

Open to Indians below 300% FPL - 34762MO0590013-02

Open to Indians above 300% FPL - 34762MO0590013-03

Last Plan Update Date Thu, 19 Sep 2024 00:00 GMT
Last Import Date Tue, 03 Dec 2024 06:24 GMT

Benefits of Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, 34762MO0590013-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental

Limit: 3000.0 Dollars per Episode

Treatment must begin within 12 months of the injury.

YES

25.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

25.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

25.00% Coinsurance after deductible

100.00%
Chiropractic Care

Chiropractic visits beyond 26 per benefit period require Prior Authorization.

YES

25.00% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

25.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

No Charge

100.00%
Dialysis

Covered Services include dialysis treatments in an outpatient dialysis, or home dialysis and training for you and the person who will help you with home self-dialysis.

YES

25.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

25.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Covered lenses and frames each available at limit of one per year.

YES

25.00% Coinsurance after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

$15.00

100.00%
Habilitation Services

Limit: 20.0 Visit(s) per Benefit Period

Habilitative services definition: 'help you keep, learn or improve skills and functioning for daily living.'

YES

$30.00

100.00%
Hearing Aids

Benefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening.

YES

25.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 100.0 Visit(s) per Benefit Period

To be eligible for benefits, you must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basis.

YES

25.00% Coinsurance after deductible

100.00%
Hospice Services
YES

25.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

25.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

25.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

25.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

25.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

25.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$30.00

100.00%
Non-Preferred Brand Drugs
YES

$60.00

100.00%
Nutritional Counseling
YES

No Charge

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$30.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

25.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Benefit Period

To be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing toward those goals.

YES

25.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$30.00

100.00%
Prenatal and Postnatal Care
YES

25.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$30.00

100.00%
Private-Duty Nursing

Limit: 82.0 Visit(s) per Benefit Period

Private duty nursing services are a Covered Service only when given as part of the 'Home Care Services' benefit. Private Duty Lifetime Maximum: 164 visits In- and Out-of-Network combined.

YES

25.00% Coinsurance after deductible

100.00%
Prosthetic Devices

Benefits include the purchase, fitting, adjustments, repairs and replacements.

YES

25.00% Coinsurance after deductible

100.00%
Radiation
YES

25.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance.

YES

25.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Benefit Period

20 visit limit each for PT and OT.

YES

$30.00

100.00%
Rehabilitative Speech Therapy

Unlimited visits for speech therapy.

YES

$30.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Benefit Period

YES

No Charge

100.00%
Routine Foot Care

Coverage is available if Medically Necessary.

YES

25.00% Coinsurance after deductible

100.00%
Skilled Nursing Facility

Limit: 150.0 Days per Benefit Period

Limit is for in-and out-of-network combined and includes rehab and outpatient day rehab.

YES

25.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$60.00

100.00%
Specialty Drugs
YES

$250.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

25.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$30.00

100.00%
Transplant
YES

25.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.

YES

25.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$45.00

$45.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

25.00% Coinsurance after deductible

100.00%

Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan Variant 34762MO0590013-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7806125763529309
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2025
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Gold Off Exchange Plan
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID MOF005
Formulary URL URL
HIOS Product ID 34762MO059
Import Date 2024-09-19 01:01:32
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 34762
Issuer Marketplace Marketing Name Blue Cross and Blue Shield of Kansas City
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID MON001
Out of Country Coverage No
Out of Country Coverage Description We provide limited services outside the United States through Global Core. Such services are limited to emergency services.
Out of Service Area Coverage No
Out of Service Area Coverage Description Services are not provided out-of-network, except in an Emergency or other limited situations. If an out-of-network service is covered and provided outside of Our Service Area, such services will be provided at the in-network benefit level. Non-emergency services that are covered out-of-network will not apply to your in-network out-of-pocket maximum.
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 34762MO0590013-00
Plan Level Exclusions All services must be rendered under the provisions of the Contract and comply with the Medical policies of the Plan. Please refer to the Member's Plan Document for more information.
Plan Marketing Name Blue KC Standard Gold Preferred-Care Blue EPO
Plan Type EPO
Plan Variant Marketing Name Blue KC Standard Gold Preferred-Care Blue EPO
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,100
SBC Scenario, Having a Baby, Copayment $70
SBC Scenario, Having a Baby, Deductible $1,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,100
SBC Scenario, Having Diabetes, Deductible $100
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $200
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID MOS003
Source Name HIOS
Plan ID 34762MO0590013
State Code MO
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $3000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,500
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $15600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7800 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,800
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, 34762MO0590013

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Blue KC Standard Gold Preferred-Care Blue EPO, 34762MO0590013 Health Insurance Plan, 34762MO0590013

  • Does Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, 34762MO0590013 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (34762MO0590013) Health Insurance Plan, Variant (34762MO0590013-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does (34762MO0590013) Health Insurance Plan, Variant (34762MO0590013-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan). Details: We provide limited services outside the United States through Global Core. Such services are limited to emergency services.

    Does (34762MO0590013) Health Insurance Plan, Variant (34762MO0590013-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: Services are not provided out-of-network, except in an Emergency or other limited situations. If an out-of-network service is covered and provided outside of Our Service Area, such services will be provided at the in-network benefit level. Non-emergency services that are covered out-of-network will not apply to your in-network out-of-pocket maximum.

    Does (34762MO0590013) Health Insurance Plan, Variant (34762MO0590013-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, Variant (34762MO0590013-00) offer Disease Management Programs for Asthma?

    Yes, the Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan Variant 34762MO0590013-00 offers Disease Management Program for Asthma.

    Does Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, Variant (34762MO0590013-00) offer Disease Management Programs for Heart disease?

    Yes, the Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan Variant 34762MO0590013-00 offers Disease Management Program for Heart disease.

    Does Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, Variant (34762MO0590013-00) offer Disease Management Programs for Depression?

    Yes, the Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan Variant 34762MO0590013-00 offers Disease Management Program for Depression.

    Does Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, Variant (34762MO0590013-00) offer Disease Management Programs for Diabetes?

    Yes, the Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan Variant 34762MO0590013-00 offers Disease Management Program for Diabetes.

    Does Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, Variant (34762MO0590013-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan Variant 34762MO0590013-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, Variant (34762MO0590013-00) offer Disease Management Programs for Pregnancy?

    Yes, the Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan Variant 34762MO0590013-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API