Blue KC Choice Silver 2 BlueSelect EPO with Spira Care – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$6,000 per person $6,000 per person
Out-of-pocket max	$8,050 per person $16,100 per family
Metal tier	Silver

Visit Copay

Primary care visit	No charge
Specialist visit	$100 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$100 copay
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	$20 copay
Brand	$75 copay
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_34762MO0590015-01.pdf
Drug and medication plan formulary	https://pharmacy.rxportal.sxc.com/oe_rxexternal/prescription-drug-list?type=ClientFormulary&var=XBLKCEXMOP&infoid=XBLKCEXMOP&clientCode=KCH
Search doctor list	https://www.bluekc.com/qhp/bs-spira