BlueCare EPO Silver – EPO
Network type: EPO
Coverage tier: Silver
Primary care visit: $35 copay
Specialist visit: $70 copay
Urgent care visit: $35 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $4,500 per person $4,500 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $70 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $35 copay |
| Emergency room | 30% coinsurance after deductible |
| Ambulance | 30% coinsurance after deductible |
| Hospital stay (facility) | 30% coinsurance after deductible |
| Hospital stay (physician) | 30% coinsurance after deductible |
| Outpatient procedure (facility) | 30% coinsurance after deductible |
| Outpatient procedure (physician) | 30% coinsurance after deductible |
| Physical rehabilitation | 30% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 30% 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 | 30% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 30% coinsurance after deductible |
| Blood work | 30% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $35 copay |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.bcbsks.com/qhp-data/plan-docs/2024/MT018_BlueCareEPOSilver_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 |
