BlueCare SignatureSG Choice with Pediatric Dental

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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.

SignatureSG Choice In-Network Out-of-Network
Deductible $2,000 per person / $4,000 family $4,000 per person / $8,000 family
(percentage paid by member)
30% 60%
Coinsurance maximum Same as the annual out-of-pocket maximum $8,000 per person / $16,000 family
Annual out-of-pocket maximum $5,500 per person / $11,000 family Includes the deductible and coinsurance maximum for health benefits only
Doctor's Office Visits
Home and office visits - Primary $35 copay for 3 visits, then subject to deductible and coinsurance Subject to deductible and coinsurance
Home and office visits - Specialists $70 copay then 100%
Preventive care These services are paid at 100%
of the allowable charge.
Some of the services include:
  • Routine screenings
  • Preventive immunizations
  • Well-woman visits/screenings
  • Contraceptive methods
Drug Coverage
Prescription drugs Subject to deductible and coinsurance
Mail order drugs Subject to deductible and coinsurance
Specialty drugs are not covered
Medical Services
Emergency medical transportation Subject to deductible and coinsurance
Inpatient surgery physician/surgical
Inpatient facility fee
Outpatient surgery physician/surgical
Outpatient lab and radiology
Advanced imaging (CT/PET scans, MRIs) $200 copay then 100% Subject to deductible and coinsurance
Emergency Room Subject to deductible and coinsurance Subject to in-network ER benefits
Injections Subject to deductible and coinsurance
Dental and Vision
Pediatric dental (for ages 0-19) Subject to deductible and coinsurance
Pediatric vision (for ages 0-19)
Recovery/Special Needs
Outpatient rehabilitation $70 copay then 100% Subject to deductible and coinsurance
Outpatient habilitation
Hospice Subject to deductible and coinsurance
Home health care
Mental Illness/Substance Use Disorders
Mental illness/substance use disorders - inpatient services
Requires pre-admission certification from New Directions Behavioral Health at 1-800-952-5906
Provided at the same payment level that is applicable to the service provided for a condition other than the mental health disorders
Mental illness/substance use disorders - outpatient services
Lifetime maximum Unlimited for each covered person
Eligible dependents Covered to age 26
HSA compliant No
Summary of Benefits and Coverage (SBC)Adobe Acrobat PDF BlueCare SignatureSG Choice with Pediatric Dental

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

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 cure; routine adult eye exams (vision benefits are provided for insureds up to age 19); 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 or supplies related to sex transformations; 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 - One time 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 - 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

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 for new hires.

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

  • Phone: Learn more about these features by calling 785-291-4303 in Topeka or toll-free at 1-800-874-1823.
  • Tell Us About Your Business and a representative will contact you about your options.