Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO

34762MO0590013
Gold
EPO

Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO is a Gold EPO plan by Blue Cross and Blue Shield of Kansas City.

IMPORTANT: You are viewing the 2023 version of Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO 34762MO0590013. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO 34762MO0590013.
Insurer: Blue Cross and Blue Shield of Kansas City
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 34762MO0590013

Cost-Sharing Overview

Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan 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.
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description:
National Network: No

Additional Benefits and Cost-Sharing

Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO includes the following benefits at the cost sharing rates listed below.

Free Preventive Services

There is no copayment or coinsurance for any of the following Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Blue KC Standard Gold 2000 with broad Preferred-Care Blue EPO?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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