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BlueCare ClassicSG Choice 4

When you choose a health insurance plan, you want to get the most out of your health care dollars – today, more than ever. Blue Cross and Blue Shield of Kansas developed BlueCare plans with you in mind. BlueCare helps put you in control of your health care.

General In-network Out-of-network
Deductible $3,800 per person / $7,600 family $6,000 per person / $12,000 family
Coinsurance (percentage paid by member) 20% 50%
Coinsurance maximum Same as the annual out-of-pocket max $5,000 per person / $10,000 family
Annual out-of-pocket maximum $7,150 per person / $14,300 family $11,000 per person / $22,000 family
Doctor's office visits In-network Out-of-network
Home and office visits - primary $35 copay per visit Deductible then 50% coinsurance
Home and office visits - specialists $70 copay per visit Deductible then 50% coinsurance
Preventive care $0 - Preventive is without cost share Deductible then 50% coinsurance
Prescription drug coverage In-network Out-of-network
Prescription drugs $15 generic / $50 brand / $75 non-formulary / $150 specialty; 20% coinsurance up to $250 max for specialty non-formulary Deductible then 50% coinsurance
Mail order drugs $37.50 generic / $125 brand / $187.50 non-formulary / $375 compound (3 month supply)
Specialty drugs are not covered
Deductible then 50% coinsurance
Specialty drugs are not covered
Medical services In-network Out-of-network
Emergency medical transportation Deductible then 20% coinsurance Deductible then 20% coinsurance
Inpatient surgery physician/surgical Deductible then 20% coinsurance Deductible then 50% coinsurance
Inpatient facility fee Deductible then 20% coinsurance Deductible then 50% coinsurance
Outpatient surgery physician/surgical Deductible then 20% coinsurance Deductible then 50% coinsurance
Outpatient lab and radiology $300 paid at 100% then subject to deductible, then 20% coinsurance Deductible then 50% coinsurance
Advanced imaging (CT/PET scans, MRIs) $300 paid at 100% then subject to deductible, then 20% coinsurance Deductible then 50% coinsurance
Emergency room Deductible then 20% coinsurance Deductible then 20% coinsurance
Injections Deductible then 20% coinsurance Deductible then 50% coinsurance
Dental and vision In-network Out-of-network
Pediatric dental (for ages 0-19) Cleanings and periodic evaluations covered at 100% - other services: Deductible then 20% coinsurance Cleanings and periodic evaluations covered at 100% - other services: Deductible then 50% coinsurance
Pediatric vision (for ages 0-19) Eye exams subject to office visit - specialist benefits, all other services deductible then 20% coinsurance Deductible then 50% coinsurance
Recovery/special needs In-network Out-of-network
Outpatient rehabilitation Deductible then 20% coinsurance Deductible then 50% coinsurance
Outpatient habilitation Deductible then 20% coinsurance Deductible then 50% coinsurance
Hospice Deductible then 20% coinsurance Deductible then 50% coinsurance
Home health care Deductible then 20% coinsurance Deductible then 50% coinsurance
Mental illness/substance use disorders In-network Out-of-network
Mental illness/substance use disorders - inpatient services
Requires pre-admission certification from New Directions Behavioral Health at 1-800-952-5906
Deductible then 20% coinsurance Deductible then 50% coinsurance
Mental illness/substance use disorders - outpatient services $35 copay per visit Deductible then 50% coinsurance
Other In-network Out-of-network
Lifetime maximum Unlimited for each covered person Unlimited for each covered person
Eligible dependents Covered to age 26 Covered to age 26
HSA compliant No No

Summary of Benefits and Coverage (SBC) for BlueCare ClassicSG Choice 4 Adobe Acrobat PDF

Exclusions: Following is a list of common non-covered services. For a complete list of limitations and exclusions, refer to your contract.

Duplicate benefits provided under federal, state or local laws, regulations or programs except Medicaid; services involving cosmetic or reconstructive surgery (except as stated in the contract); charges for personal items; convalescent or custodial care or rest care; all keratotomy procedures; blood or payments to donors of blood; any service or supply related to the medical management of obesity, except services covered as preventive health benefits; services related to the reversal of sterilization procedures; any medically-aided insemination procedure; charges for services by immediate relatives or by members of the household; acupuncture and admission for acupuncture; medically unnecessary services and admissions; services covered and payable under any medical expense payment provision of any automobile insurance policy; mental illness or substance use disorder services provided by a non-eligible provider; services, supplies or treatments not specifically listed as covered in the member’s contract.

Drug coverage limitation: Generic drugs are mandatory if available unless physician prescribes a brand drug.

Specialty drug coverage: In-network benefits are applied when specialty drugs are obtained from Prime Specialty Pharmacy.

Pediatric Dental (included for ages 0-19)

Preventive Services

  • Cleanings - Covered 100%, once every six months
  • Fluoride treatments - Up to three times yearly
  • Sealants - One time a year per tooth
    Limitations include occlusal surface only, teeth must be free of caries (tooth decay), not covered when placed over restoration.
  • Space maintainers - One time per year
    Covered when medically indicated due to premature loss of posterior primary tooth; recementation not covered within six months of initial placement.

Diagnostic Services

  • Periodic dental evaluation - Covered 100%, once every six months
  • Comprehensive evaluation - One per insured, per dentist per lifetime
  • X-rays
    • Bitewing
    • Full mouth and panoramic - Once every three years

Treatment Services

  • Fillings
    • Silver amalgam
    • Tooth colored composite
  • Crowns
    • Stainless steel - Once per 24 months per tooth
    • Metal only, metal/porcelain or porcelain only - Once per 60 months per tooth
      An approval process (known as "prior authorization") for determining if services will be considered for payment is required for all crowns except stainless steel.
  • Root canals
    • Root canals on baby teeth - One per tooth per lifetime
    • Root canals on permanent teeth - One per tooth per lifetime
  • The treatment services listed below also require prior authorization to be considered for payment.
    • Periodontal therapy
    • Full and partial dentures (once every 60 months)
    • Orthodontics

Dental services are subject to applicable deductible, coinsurance or annual out-of-pocket maximum.

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Pediatric Vision (included for ages 0-19)

Eye Exams

  • Basic exams are covered as needed when provided by ophthalmologists and optometrists
  • Two exams per month to detect and/or follow medical conditions
  • As needed up to one year following cataract surgery

Eyeglasses (standard frames)

  • Frames must include a one-year warranty
  • Up to three pairs of frames per 365 days
  • Up to three sets of lenses per 365 days
  • Eyeglasses provided for post cataract surgery within one year of surgery

Contact Lenses
Contact lenses require prior authorization

Blepharoplasty and Blepharoptosis
Surgery for the correction of eyelid defects requires prior authorization

Exclusions
Although this is not a complete list, your pediatric vision coverage excludes items such as LASIK surgery, sunglasses, safety glasses, athletic glasses, backup eyeglasses and contact lenses for cosmetic purposes.

Vision services are subject to applicable deductible, coinsurance or annual out-of-pocket maximum.

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Optional Benefits:

Additional Program Information

  • Inpatient Admissions - Pre-admission certification is required for all planned inpatient admissions.
  • Benefit Period - The 12-month period based on the group anniversary month.
  • Waiting Period - Businesses select a waiting period option.

Dual Option Plan
The Dual Option Plan is available to groups of 2 to 50 employees with this product. The plan offers employees one of two out-of-pocket choices annually. This provides employees the option to "buy up" to a better level of coverage, based on their personal insurance needs.

More Information
Contact us to learn more about the features of ClassicSG Choice 4.