BlueCare EPO Gold – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$1,500 per person $1,500 per person
Out-of-pocket max	$4,950 per person $9,900 per family
Metal tier	Gold

Visit Copay

Primary care visit	$25 copay, 20% coinsurance after deductible
Specialist visit	$50 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$25 copay, 20% coinsurance after deductible
Emergency room	$300 copay after deductible, 20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$10 copay
Brand	$65 copay
Non-preferred Brand	$100 copay
Specialty	25% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$25 copay
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsks.com/qhp-data/plan-docs/2024/MT010_BlueCareEPOGold_2024.pdf
Drug and medication plan formulary	https://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_KS_7T_BlueCare_Medication_List.pdf
Search doctor list	https://www.bcbsks.com/ProviderDirectory/?prefix=XSN