BlueCare EPO Silver Plus – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$5,500 per person $5,500 per person
Out-of-pocket max	$7,350 per person $14,700 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	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	$10 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	$35 copay
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.bcbsks.com/qhp-data/plan-docs/2024/MT033_BlueCareEPOSilverPlus_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