Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care - 34762MO0590002 Health Insurance Plan

Blue Cross and Blue Shield of Kansas City health insurance plan with the Plan ID 34762MO0590002. The plan is called Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.31% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.69% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 34762MO0590002
Health Insurance Plan Year 2023
State Missouri
Health Insurance Issuer Blue Cross and Blue Shield of Kansas City
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 34762MO0590002-01
Provider Network(s) ['MON004']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Missouri All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard On Exchange Plan - 34762MO0590002-01

Open to Indians below 300% FPL - 34762MO0590002-02

Open to Indians above 300% FPL - 34762MO0590002-03

73% AV Silver Plan - 34762MO0590002-04

87% AV Silver Plan - 34762MO0590002-05

94% AV Silver Plan - 34762MO0590002-06

Last Plan Update Date Fri, 06 Jan 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan, 34762MO0590002-01

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

50.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

50.00% Coinsurance after deductible

100.00%
Applied Behavior Analysis Based Therapies

Exclusions: Covered services do not include Applied Behavior Analysis services received as part of any Part C early intervention program or provided by any school district. Applied Behavior Analysis does not include cognitive therapies or psychological testing, personality assessment, intellectual assessment, neuropsychological assessment, psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy, family therapy, and long-term counseling as treatment modalities.

Covered services are limited to Medically Necessary treatment ordered by the treating physician or psychologist for Covered Persons under the age of 19. Covered services are limited to the diagnosis and treatment when prescribed or ordered for an individual diagnosed with an Autism Spectrum Disorder by a licensed Physician or licensed psychologist. Autism service providers are limited to any person, entity, or group providing diagnostic or treatment services for Autism Spectrum Disorders that are licensed or certified by the state in which services were rendered to provide health care services; or any person who is licensed under Missouri Chapter 377 as a board certified behavior analyst by the behavior analyst certification board or as an assistant board certified behavior analyst.

YES

50.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Bone Marrow Testing
YES

50.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

50.00% Coinsurance after deductible

100.00%
Chiropractic Care
YES

50.00% Coinsurance after deductible

100.00%
Clinical Trials

Covered services do not include the investigational item, device, or service itself; items and services provided solely to satisfy data collection and analysis needs that are not used in the direct clinical management of the patient; costs for services clearly inconsistent with widely accepted standards of care for a particular dianosis; and items and services customarily provided by the research sponsors free of charge for any enrollee in the trial

YES

50.00% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

50.00% Coinsurance after deductible

100.00%
Dental Anesthesia
YES

50.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Limit: 1.0 Item(s) per Year

YES

Tier 1: No Charge

Tier 2: No Charge

100.00%
Dialysis
YES

50.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Limit: 1.0 Item(s) per Year

Mastectomy bras are covered up to 4 per Calendar Year. See Plan Documents for more information.

YES

50.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Coverage includes up to 3 pair of lenses and frames or an annual supply of contact lenses in lieu of eyeglasses, per Calendar Year. See Plan Documents for more information.

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

This tier may offer a Preferred "low cost" Generic copay, see the Prescription Drug formulary for more information.

YES

$5.00

100.00%
Habilitation Services

Limit: 20.0 Visit(s) per Year

YES

50.00% Coinsurance after deductible

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

YES

50.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 100.0 Visit(s) per Year

Up to 3 educational visits are covered per Calendar Year. See Plan Documents for more information.

YES

50.00% Coinsurance after deductible

100.00%
Hospice Services
YES

50.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

50.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

50.00% Coinsurance after deductible

100.00%
Inherited Metabolic Disorder - PKU
YES

50.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

50.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

50.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Newborn Services Other
YES

50.00% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs
YES

$250.00

100.00%
Nutritional Counseling
YES

50.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)

This Plan offers $0 copay to Spira Care for your doctor's visit, counseling, and any associated lab or x-rays prescribed by a Spira Care physician. You also have a $0 copay to telehealth visits with your doctor. Save money and time when you use telehealth. See Plan Documents for more information about other services obtained from other providers in our network.

YES

Tier 1: No Charge

Tier 2: $50.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

50.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Year

YES

50.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$75.00

100.00%
Prenatal and Postnatal Care
YES

50.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

Tier 1: No Charge

Tier 2: No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

This Plan offers $0 copay to Spira Care for your doctor's visit, counseling, and any associated lab or x-rays prescribed by a Spira Care physician. You also have a $0 copay to telehealth visits with your doctor. Save money and time when you use telehealth. See Plan Documents for more information about other services obtained from other providers in our network.

YES

Tier 1: No Charge

Tier 2: $50.00

100.00%
Private-Duty Nursing

Limit: 100.0 Visit(s) per Year

YES

50.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

50.00% Coinsurance after deductible

100.00%
Radiation
YES

50.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Year

YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy
YES

50.00% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

$25.00

100.00%
Routine Foot Care
YES

50.00% Coinsurance after deductible

100.00%
Skilled Nursing Facility

Limit: 150.0 Visit(s) per Year

YES

50.00% Coinsurance after deductible

100.00%
Specialist Visit

You have a $0 copay to telehealth visits with your doctor. Save money and time when you use telehealth. See Plan Documents for more information about other services obtained from other providers in our network.

YES

$100.00

100.00%
Specialty Drugs

This tier may offer a Preferred Specialty medication copay, see the Prescription Drug formulary for more information.

YES

$350.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Transplant

Limit: 60.0 Days per Year

YES

50.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

50.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities

Save money and time with BlueKC Virtual Care. You may access virtual care for a $0 copay, 24/7.

YES

$75.00

$75.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

Tier 1: No Charge

Tier 2: No Charge

100.00%
X-rays and Diagnostic Imaging
YES

50.00% Coinsurance after deductible

100.00%

Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan Variant 34762MO0590002-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.713085957
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Silver On Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 45%
Formulary ID MOF011
Formulary URL URL
HIOS Product ID 34762MO059
Import Date 1/6/2023 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 34762
Issuer Marketplace Marketing Name Blue Cross and Blue Shield of Kansas City
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers Yes
National Network No
Network ID MON004
Out of Country Coverage No
Out of Service Area Coverage No
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 34762MO0590002-01
Plan Level Exclusions Services received from Out-of-Network Providers except as specified. Services received if there is no obligation for payment or payment has been fully or partially waived. Subject to Prior Auth when approval was not obtained. Not Medically Necessary. Not specifically covered under the Contract. Experimental/Investigative as determined by Us except as provided. For services You are entitled to at no cost for military service related conditions. Losses due in whole or in part to war or any action of war. For court ordered services, including but not limited to examinations, treatment, and genetic testing. For Mason Shunt, banding, gastroplasty, intestinal bypass, gastric balloons, stomach stapling, jejunal bypass, wiring of the jaw and services of a similar nature. For hairplasty or hair removal, regardless of reason or diagnosis. For health and dental services resulting from Accidental Injuries arising out of motor vehicle accidents to the extent such services are payable under any expense payment provision (by whatever term used, including benefits mandated by law) of any automobile insurance policy. Except as provided, for charges when no direct patient contact is provided including but not limited to Physician team conferences, for missed appointments, for completion of forms or other non-medical charges. Health Care Services which are related to complications arising from treatments or services otherwise excluded. For non-prescription enteral feedings and other nutritional and electrolyte supplements. For any diagnosis or treatment of impotency, including drugs. Services or supplies received from any provider in a country where any sanction, embargo, etc. would prohibit payment or reimbursement. Sales tax. Services, supplies, equipment or care received in connection with a non-covered service. Services and supplies to the extent they are payable by Medicare.
Plan Marketing Name Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care
Plan Type EPO
Plan Variant Marketing Name Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care
QHP/Non QHP On the Exchange
SBC Scenario, Having a Baby, Coinsurance $1,900
SBC Scenario, Having a Baby, Copayment $100
SBC Scenario, Having a Baby, Deductible $5,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,900
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,600
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 55%
Service Area ID MOS001
Source Name HIOS
Plan ID 34762MO0590002
State Code MO
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $10000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,000
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $10000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $5000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $5,000
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $16000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $16000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $8000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $8,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan, 34762MO0590002

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care, 34762MO0590002 Health Insurance Plan, 34762MO0590002

  • Does Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan, 34762MO0590002 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (34762MO0590002) Health Insurance Plan, Variant (34762MO0590002-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does (34762MO0590002) Health Insurance Plan, Variant (34762MO0590002-01) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (34762MO0590002) Health Insurance Plan, Variant (34762MO0590002-01) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

    Does (34762MO0590002) Health Insurance Plan, Variant (34762MO0590002-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan, Variant (34762MO0590002-01) offer Disease Management Programs for Asthma?

    Yes, the Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan Variant 34762MO0590002-01 offers Disease Management Program for Asthma.

    Does Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan, Variant (34762MO0590002-01) offer Disease Management Programs for Heart disease?

    Yes, the Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan Variant 34762MO0590002-01 offers Disease Management Program for Heart disease.

    Does Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan, Variant (34762MO0590002-01) offer Disease Management Programs for Depression?

    Yes, the Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan Variant 34762MO0590002-01 offers Disease Management Program for Depression.

    Does Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan, Variant (34762MO0590002-01) offer Disease Management Programs for Diabetes?

    Yes, the Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan Variant 34762MO0590002-01 offers Disease Management Program for Diabetes.

    Does Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan, Variant (34762MO0590002-01) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan Variant 34762MO0590002-01 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan, Variant (34762MO0590002-01) offer Disease Management Programs for Pregnancy?

    Yes, the Blue KC Choice Silver 5000 BlueSelect Plus EPO with Spira Care Health Insurance Plan Variant 34762MO0590002-01 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API