Blue KC Choice Bronze 1 BlueSelect EPO with Spira Care – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$7,000 per person $7,000 per person
Out-of-pocket max	$9,050 per person $18,100 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	No charge
Specialist visit	50% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	50% coinsurance after deductible
Emergency room	50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$30 copay
Brand	50% coinsurance after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	50% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	50% coinsurance after deductible
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://bkcdocs.blob.core.windows.net/qhp/SBC_2024_94248KS0560005-01.pdf
Drug and medication plan formulary	https://pharmacy.rxportal.sxc.com/oe_rxexternal/prescription-drug-list?type=ClientFormulary&var=XBLKCEXKSP&infoid=XBLKCEXKSP&clientCode=KCH
Search doctor list	https://www.bluekc.com/qhp/bs-spira