BlueCare℠ Solutions GoldSG Choice
High quality coverage at more affordable premiums is what you can expect from BlueCross BlueShield Kansas Solutions. You'll also enjoy access to our exclusive network of physicians and hospitals making your health care plan a total health solution.
|Deductible||$1,500 per person / $3,000 family||Out-of-Network services are not available, except services for medical emergencies and covered services not available in-network.|
|Coinsurance (percentage paid by member)||20%|
|Coinsurance maximum||Same as the annual out-of-pocket max|
|Annual out-of-pocket maximum||$4,500 per person / $9,000 family|
|Doctor's office visits||In-network||Out-of-network|
|Home and office visits - primary||$25 copay for 5 visits, then subject to deductible and 20% coinsurance|
|Home and office visits - specialists||$50 copay per visit|
|Preventive care||$0 - Preventive is without cost share|
|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|
|Mail order drugs||$37.50 generic / $125 brand / $187.50 non-formulary / $375 compound (3 month supply)
Specialty drugs are not covered
|Emergency medical transportation||Deductible then 20% coinsurance||Deductible then 20% coinsurance|
|Inpatient surgery physician/surgical||Deductible then 20% coinsurance|
|Inpatient facility fee||Deductible then 20% coinsurance|
|Outpatient surgery physician/surgical||Deductible then 20% coinsurance|
|Outpatient lab and radiology||Deductible then 20% coinsurance|
|Advanced imaging (CT/PET scans, MRIs)||Deductible then 20% coinsurance|
|Emergency room||$300 copay then subject to deductible and 20% coinsurance||$300 copay then subject to deductible and 20% coinsurance|
|Injections||Deductible then 20% 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|
|Pediatric vision (for ages 0-19)||Eye exams subject to office visit - specialist benefits, all other services deductible then 20% coinsurance|
|Outpatient rehabilitation||Deductible then 20% coinsurance|
|Outpatient habilitation||Deductible then 20% coinsurance|
|Hospice||Deductible then 20% coinsurance|
|Home health care||Deductible then 20% 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|
|Mental illness/substance use disorders - outpatient services||$25 copay per visit|
|Lifetime maximum||Unlimited for each covered person|
|Eligible dependents||Covered to age 26|
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)
- 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.
- Periodic dental evaluation - Covered 100%, once every six months
- Comprehensive evaluation - One per insured, per dentist per lifetime
- Full mouth and panoramic - Once every three years
- Silver amalgam
- Tooth colored composite
- 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)
Dental services are subject to applicable deductible, coinsurance or annual out-of-pocket maximum.
Pediatric Vision (included for ages 0-19)
- 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 require prior authorization
Blepharoplasty and Blepharoptosis
Surgery for the correction of eyelid defects requires prior authorization
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.
- Dental Program (for additional coverage beyond the included pediatric dental benefits)
- Hospital Indemnity Plan (S-HIP)
- Life Insurance
- Cancer Plan (Secure 300)
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.
Contact us to learn more about the features of Solutions GoldSG Choice.