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 | 34762MO0590013-01 | ||||||||||||||||||
| Provider Network(s) | NETWORK PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 04 Nov 2025 05:30 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 34762MO0590013-00 Standard On Exchange Plan - 34762MO0590013-01 |
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| Last Plan Update Date | Thu, 19 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 04 Nov 2025 05:30 GMT |
Benefits of Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, 34762MO0590013-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Limit: 3000.0 Dollars per Episode Exclusions: nan Treatment must begin within 12 months of the injury. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Exclusions: nan Chiropractic visits beyond 26 per benefit period require Prior Authorization. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Education
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Dialysis
Exclusions: nan 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
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan Covered lenses and frames each available at limit of one per year. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
NO | ||
| Generic Drugs
Exclusions: nan nan |
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Benefit Period Exclusions: nan Habilitative services definition: 'help you keep, learn or improve skills and functioning for daily living.' |
YES | $30.00 |
100.00% |
| Hearing Aids
Exclusions: nan 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 Exclusions: nan 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
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Exclusions: nan nan |
NO | ||
| Infusion Therapy
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan nan |
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: nan nan |
YES | $60.00 |
100.00% |
| Nutritional Counseling
Exclusions: nan nan |
YES | No Charge |
100.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Benefit Period Exclusions: nan 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
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: nan nan |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan nan |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan nan |
YES | $30.00 |
100.00% |
| Private-Duty Nursing
Limit: 82.0 Visit(s) per Benefit Period Exclusions: nan 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
Exclusions: nan Benefits include the purchase, fitting, adjustments, repairs and replacements. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Radiation
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: nan 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 Exclusions: nan 20 visit limit each for PT and OT. |
YES | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Exclusions: nan Unlimited visits for speech therapy. |
YES | $30.00 |
100.00% |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period Exclusions: nan nan |
YES | No Charge |
100.00% |
| Routine Foot Care
Exclusions: nan Coverage is available if Medically Necessary. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Skilled Nursing Facility
Limit: 150.0 Days per Benefit Period Exclusions: nan 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
Exclusions: nan nan |
YES | $60.00 |
100.00% |
| Specialty Drugs
Exclusions: nan nan |
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan nan |
YES | $30.00 |
100.00% |
| Transplant
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan 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
Exclusions: nan nan |
YES | $45.00 |
$45.00 |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan nan |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | 25.00% Coinsurance after deductible |
100.00% |
Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan Variant 34762MO0590013-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.780612576352931 |
| 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 On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, Heart Disease, 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) | 34762MO0590013-01 |
| 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
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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 (34762MO0590013-01) offer Disease Management Programs?
Does (34762MO0590013) Health Insurance Plan, Variant (34762MO0590013-01) have Out Of Country Coverage?
Does (34762MO0590013) Health Insurance Plan, Variant (34762MO0590013-01) have Out of Service Area Coverage?
Does (34762MO0590013) Health Insurance Plan, Variant (34762MO0590013-01) offer Disease Management Programs?
Does Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, Variant (34762MO0590013-01) offer Disease Management Programs for Asthma?
Does Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, Variant (34762MO0590013-01) offer Disease Management Programs for Heart disease?
Does Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, Variant (34762MO0590013-01) offer Disease Management Programs for Depression?
Does Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, Variant (34762MO0590013-01) offer Disease Management Programs for Diabetes?
Does Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, Variant (34762MO0590013-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Blue KC Standard Gold Preferred-Care Blue EPO Health Insurance Plan, Variant (34762MO0590013-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 04 Nov 2025 05:30 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