BlueCare℠ SignatureSG Choice with Pediatric Dental
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.
|Deductible||$2,000 per person / $4,000 family||$4,000 per person / $8,000 family|
(percentage paid by member)
|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:
|Prescription drugs||Subject to deductible and coinsurance|
|Mail order drugs||Subject to deductible and coinsurance
Specialty drugs are not covered
|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)|
|Outpatient rehabilitation||$70 copay then 100%||Subject to deductible and coinsurance|
|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|
|Summary of Benefits and Coverage (SBC)||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)
- 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.
- Periodic dental evaluation - 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
- Life Insurance
- Plan 150 (Cancer Policy)
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.
Contact us to learn more about the features of SignatureSG Choice.