Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care - 34762MO0590004 Health Insurance Plan

Blue Cross and Blue Shield of Kansas City health insurance plan with the Plan ID 34762MO0590004. The plan is called Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.30% (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 29.70% 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 34762MO0590004
Health Insurance Plan Year 2022
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 34762MO0590004-01
Provider Network(s) ['MON005']
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 - 34762MO0590004-01

Open to Indians below 300% FPL - 34762MO0590004-02

Open to Indians above 300% FPL - 34762MO0590004-03

73% AV Silver Plan - 34762MO0590004-04

87% AV Silver Plan - 34762MO0590004-05

94% AV Silver Plan - 34762MO0590004-06

Last Plan Update Date Thu, 02 Dec 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care Health Insurance Plan Variant 34762MO0590004-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.703003927
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Silver On Exchange Plan
Dental Only Plan No
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 8%
Formulary ID MOF003
Formulary URL URL
HIOS Product ID 34762MO059
Import Date 12/2/2021 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 MON005
Out of Country Coverage No
Out of Service Area Coverage No
Out of Service Area Coverage Description Services are not provided out-of-network, except in an Emergency, Urgent Care, or other limited situations. If an out-of-network service is covered and provided outside of Our Service Area, such services will be provided at the in-network benefit level. Non-emergency services that are covered out-of-network will not apply to your in-network out-of-pocket maximum.
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 34762MO0590004-01
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. Services You are entitled to at no cost for military service related conditions. Losses due in whole or in part to war/any action of war. Court ordered services, including but not limited to examinations, treatment, and genetic testing. Mason Shunt, banding, gastroplasty, intestinal bypass, gastric balloons, stomach stapling, jejunal bypass, wiring of the jaw and services of a similar nature. Hairplasty or hair removal, regardless of reason or diagnosis. Health/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. Services which are related to complications arising from treatments or services otherwise excluded. Non-prescription enteral feedings and other nutritional and electrolyte supplements. Diagnosis/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, supply, equipment or care. Services and supplies to the extent they are payable by Medicare.
Plan Marketing Name Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care
Plan Type EPO
Plan Variant Marketing Name Blue KC Choice Silver 5000 BlueSelect 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 $1,700
SBC Scenario, Having Diabetes, Deductible $100
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 92%
Service Area ID MOS002
Source Name HIOS
Plan ID 34762MO0590004
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 40.00%
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 40.00%
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 $14000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $14000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $7000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $7,000
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 EPO with Spira Care Health Insurance Plan, 34762MO0590004

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 EPO with Spira Care, 34762MO0590004 Health Insurance Plan, 34762MO0590004

  • Does Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care Health Insurance Plan, 34762MO0590004 support Mail Ordering?

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

  • Does (34762MO0590004) Health Insurance Plan, Variant (34762MO0590004-01) 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 (34762MO0590004) Health Insurance Plan, Variant (34762MO0590004-01) have Out Of Country Coverage?

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

    Does (34762MO0590004) Health Insurance Plan, Variant (34762MO0590004-01) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: Services are not provided out-of-network, except in an Emergency, Urgent Care, or other limited situations. If an out-of-network service is covered and provided outside of Our Service Area, such services will be provided at the in-network benefit level. Non-emergency services that are covered out-of-network will not apply to your in-network out-of-pocket maximum.

    Does (34762MO0590004) Health Insurance Plan, Variant (34762MO0590004-01) 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 EPO with Spira Care Health Insurance Plan, Variant (34762MO0590004-01) offer Disease Management Programs for Asthma?

    Yes, the Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care Health Insurance Plan Variant 34762MO0590004-01 offers Disease Management Program for Asthma.

    Does Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care Health Insurance Plan, Variant (34762MO0590004-01) offer Disease Management Programs for Heart disease?

    Yes, the Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care Health Insurance Plan Variant 34762MO0590004-01 offers Disease Management Program for Heart disease.

    Does Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care Health Insurance Plan, Variant (34762MO0590004-01) offer Disease Management Programs for Depression?

    Yes, the Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care Health Insurance Plan Variant 34762MO0590004-01 offers Disease Management Program for Depression.

    Does Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care Health Insurance Plan, Variant (34762MO0590004-01) offer Disease Management Programs for Diabetes?

    Yes, the Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care Health Insurance Plan Variant 34762MO0590004-01 offers Disease Management Program for Diabetes.

    Does Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care Health Insurance Plan, Variant (34762MO0590004-01) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care Health Insurance Plan Variant 34762MO0590004-01 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care Health Insurance Plan, Variant (34762MO0590004-01) offer Disease Management Programs for Pregnancy?

    Yes, the Blue KC Choice Silver 5000 BlueSelect EPO with Spira Care Health Insurance Plan Variant 34762MO0590004-01 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