Blue Cross and Blue Shield of Kansas City

Blue KC Community Gold 1500 with broad Preferred-Care Blue EPO

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Plan Overview

Combined Medical and Drug Deductible	Individual: $1,500.00 Family: $3,000 Per Person: $1,500
Combined Medical and Drug Out of Pocket Maximum	Individual: $5,000.00 Family: $10,000 Per Person: $5,000

Office Visit

Primary Doctor

CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Covered services do not include screening examinations or services available, arranged by, or received from any governmental body or entity, including school districts. Covered services do not include hypnotism, hypnotic anesthesia, acupuncture, acupressure, rolfing, massage therapy and/or any services provided by a massage therapist, aromatherapy and other forms of alternative treatment. Except if provided by a designated telehealth provider and as specifically provided, covered services do not include charges incurred as a result of virtual office visits on the Internet, including those for prescription drugs. A virtual office visit on the Internet occurs when a Covered Person was not physically seen or physically examined. Covered services do not include injuries or illnesses related to Your job to the extent You are covered or are required to be covered by a state or federal workers' compensation law or any comparable benefit that provides medical coverage for work-related injuries or illness whether or not You file a claim. If You enter into a settlement giving up Your right to recover past or future medical benefits under a workers' compensation law, We will not pay past or future medical benefits that are the subject of or related to that settlement. In addition if You are covered by a workers' compensation program that limits benefits to certain authorized providers, We will not pay for services You receive from providers, authorized or unauthorized, by Your workers' compensation program.
Benefit Explanation: Coverage includes telehealth services provided by a designated telehealth provider. The BlueSelect Plus network offers affordability by using a smaller network of hospitals and physicians.

Specialist

CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Covered services do not include screening examinations or services available, arranged by, or received from any governmental body or entity, including school districts. Covered services do not include hypnotism, hypnotic anesthesia, acupuncture, acupressure, rolfing, massage therapy and/or any services provided by a massage therapist, aromatherapy and other forms of alternative treatment. Except if provided by a designated telehealth provider and as specifically provided, covered services do not include charges incurred as a result of virtual office visits on the Internet, including those for prescription drugs. A virtual office visit on the Internet occurs when a Covered Person was not physically seen or physically examined. Covered services do not include injuries or illnesses related to Your job to the extent You are covered or are required to be covered by a state or federal workers' compensation law or any comparable benefit that provides medical coverage for work-related injuries or illness whether or not You file a claim. If You enter into a settlement giving up Your right to recover past or future medical benefits under a workers' compensation law, We will not pay past or future medical benefits that are the subject of or related to that settlement. In addition if You are covered by a workers' compensation program that limits benefits to certain authorized providers, We will not pay for services You receive from providers, authorized or unauthorized, by Your workers' compensation program.
Benefit Explanation: Coverage includes telehealth services provided by a designated telehealth provider.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $55.00 CoInsurance: Not Applicable Covered: Covered Exclusions: Covered services do not include drugs not on the formulary drug list; appetite suppressants, anorexiants and anti-obesity drugs; infertility drugs; compounded medications with ingredients that do not require a prescription; experimental or investigative services and medications; medications used for Experimental indications and/or dosage regimens determined by Us to be Experimental; medications for cosmetic purposes, e.g. isotretinoin, tretinoin (Retin-A), topical minoxidil, and finasteride; non-prescription/over-the-counter medications for smoking cessation or deterrents (e.g. nicotine replacement or other pharmacological agents used for smoking cessation, except as provided); medications and other items available over-the-counter or equivalent, that do not require a prescription order or refill by federal or state law (whether provided with or without a prescription, except as specified in the Routine Preventive Care Benefit); medications with no approved FDA indications; Immunization agents; Drugs related to treatment that is not a Covered Service under the Contract; prescription drugs not Medically Necessary unless otherwise specified; anabolic steroids, anti-wrinkle agents, dietary supplements, Fluoride supplements, blood or blood plasma, irrigational solutions and supplies; lifestyle enhancing drugs, unlessotherwise specified; impotency medications/devices; drugs for the first 6 months following FDA approval unless a shorter period is recommended by Our Pharmacy and Therapeutics Committee; drugs/devices intended to induce an abortion; drugs obtained outside the United States for consumption in the United States; medicines that do not require a prescription for their use, except as otherwise specified in the Routine Preventive Care Benefit, or prescription drugs purchased from a Physician for self-administration outside a Hospital. Benefit Explanation: Certain specialty drugs are required to be obtained from a designated specialty pharmacy and may not be obtained at a retail pharmacy. Manufacturer-funded Copayment assistance (Drug Copayment card dollars) will be excluded from the deductible and out-of-pocket maximum accumulators.
Non Preferred Brand Drugs	CoPay: $175.00 CoInsurance: Not Applicable Covered: Covered Exclusions: Covered services do not include drugs not on the formulary drug list; appetite suppressants, anorexiants and anti-obesity drugs; infertility drugs; compounded medications with ingredients that do not require a prescription; experimental or investigative services and medications; medications used for Experimental indications and/or dosage regimens determined by Us to be Experimental; medications for cosmetic purposes, e.g. isotretinoin, tretinoin (Retin-A), topical minoxidil, and finasteride; non-prescription/over-the-counter medications for smoking cessation or deterrents (e.g. nicotine replacement or other pharmacological agents used for smoking cessation, except as provided); medications and other items available over-the-counter or equivalent, that do not require a prescription order or refill by federal or state law (whether provided with or without a prescription, except as specified in the Routine Preventive Care Benefit); medications with no approved FDA indications; Immunization agents; Drugs related to treatment that is not a Covered Service under the Contract; prescription drugs not Medically Necessary unless otherwise specified; anabolic steroids, anti-wrinkle agents, dietary supplements, Fluoride supplements, blood or blood plasma, irrigational solutions and supplies; lifestyle enhancing drugs, unlessotherwise specified; impotency medications/devices; drugs for the first 6 months following FDA approval unless a shorter period is recommended by Our Pharmacy and Therapeutics Committee; drugs/devices intended to induce an abortion; drugs obtained outside the United States for consumption in the United States; medicines that do not require a prescription for their use, except as otherwise specified in the Routine Preventive Care Benefit, or prescription drugs purchased from a Physician for self-administration outside a Hospital. Benefit Explanation: Certain specialty drugs are required to be obtained from a designated specialty pharmacy and may not be obtained at a retail pharmacy. Manufacturer-funded Copayment assistance (Drug Copayment card dollars) will be excluded from the deductible and out-of-pocket maximum accumulators.
Generic Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Exclusions: Covered services do not include drugs not on the formulary drug list; appetite suppressants, anorexiants and anti-obesity drugs; infertility drugs; compounded medications with ingredients that do not require a prescription; experimental or investigative services and medications; medications used for Experimental indications and/or dosage regimens determined by Us to be Experimental; medications for cosmetic purposes, e.g. isotretinoin, tretinoin (Retin-A), topical minoxidil, and finasteride; non-prescription/over-the-counter medications for smoking cessation or deterrents (e.g. nicotine replacement or other pharmacological agents used for smoking cessation, except as provided); medications and other items available over-the-counter or equivalent, that do not require a prescription order or refill by federal or state law (whether provided with or without a prescription, except as specified in the Routine Preventive Care Benefit); medications with no approved FDA indications; Immunization agents; Drugs related to treatment that is not a Covered Service under the Contract; prescription drugs not Medically Necessary unless otherwise specified; anabolic steroids, anti-wrinkle agents, dietary supplements, Fluoride supplements, blood or blood plasma, irrigational solutions and supplies; lifestyle enhancing drugs, unlessotherwise specified; impotency medications/devices; drugs for the first 6 months following FDA approval unless a shorter period is recommended by Our Pharmacy and Therapeutics Committee; drugs/devices intended to induce an abortion; drugs obtained outside the United States for consumption in the United States; medicines that do not require a prescription for their use, except as otherwise specified in the Routine Preventive Care Benefit, or prescription drugs purchased from a Physician for self-administration outside a Hospital. Benefit Explanation: Certain specialty drugs are required to be obtained from a designated specialty pharmacy and may not be obtained at a retail pharmacy. Manufacturer-funded Copayment assistance (Drug Copayment card dollars) will be excluded from the deductible and out-of-pocket maximum accumulators.
Specialty Drugs	CoPay: $250.00 CoInsurance: Not Applicable Covered: Covered Exclusions: Covered services do not include drugs not on the formulary drug list; appetite suppressants, anorexiants and anti-obesity drugs; infertility drugs; compounded medications with ingredients that do not require a prescription; experimental or investigative services and medications; medications used for Experimental indications and/or dosage regimens determined by Us to be Experimental; medications for cosmetic purposes, e.g. isotretinoin, tretinoin (Retin-A), topical minoxidil, and finasteride; non-prescription/over-the-counter medications for smoking cessation or deterrents (e.g. nicotine replacement or other pharmacological agents used for smoking cessation, except as provided); medications and other items available over-the-counter or equivalent, that do not require a prescription order or refill by federal or state law (whether provided with or without a prescription, except as specified in the Routine Preventive Care Benefit); medications with no approved FDA indications; Immunization agents; Drugs related to treatment that is not a Covered Service under the Contract; prescription drugs not Medically Necessary unless otherwise specified; anabolic steroids, anti-wrinkle agents, dietary supplements, Fluoride supplements, blood or blood plasma, irrigational solutions and supplies; lifestyle enhancing drugs, unlessotherwise specified; impotency medications/devices; drugs for the first 6 months following FDA approval unless a shorter period is recommended by Our Pharmacy and Therapeutics Committee; drugs/devices intended to induce an abortion; drugs obtained outside the United States for consumption in the United States; medicines that do not require a prescription for their use, except as otherwise specified in the Routine Preventive Care Benefit, or prescription drugs purchased from a Physician for self-administration outside a Hospital. Benefit Explanation: Certain specialty drugs are required to be obtained from a designated specialty pharmacy and may not be obtained at a retail pharmacy. Manufacturer-funded Copayment assistance (Drug Copayment card dollars) will be excluded from the deductible and out-of-pocket maximum accumulators.

Inpatient Coverage

Hospital Services

CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Exclusions: Personal care or convenience items are not covered. Covered services do not include collection and storage of autologous (self-donated) blood, umbilical cord blood, or any other blood or blood product in the absence of a known disease or planned surgical procedure.
Benefit Explanation: The BlueSelect Plus network offers affordability by using a smaller network of hospitals and physicians. Coverage includes telehealth services provided by a designated telehealth provider.

Inpatient Services

CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Exclusions: Covered services do not include any activities of internship or residency, or any type of training. Covered services do not include staff consultations required by Hospital rules and regulations.

Emergency and Urgent Care

Emergency Room

CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Exclusions: Covered services do not include those provided for an Emergency Medical Condition in excess of the first 24 hours if We are not notified within 24 hours of the Admission, or as soon as reasonably possible. Covered Services do not include those which are obtained in an emergency room which are not Emergency Services.
Benefit Explanation: Services will be covered under this Benefit to evaluate or treat an Emergency Medical Condition. If You become stabilized and Your health condition no longer meets the defintion of an Emergency Medical Condition, then any subsequent admission must be at an In-Network Hospital and will be covered under the Inpatient Hospital Services benefit.

Urgent Care Facility

CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Coverage includes telehealth services provided by a designated telehealth provider.

Maternity

Labor and Delivery Hospital Stay

CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Exclusions: Covered services do not include elective pregnancy termination. Elective Pregnancy Termination does not include spontaneous abortion or services to prevent the death of the mother upon whom the procedure is performed.
Benefit Explanation: Covered services include an inpatient stay of at least 48 hours for a covered mother and a covered newborn child following any vaginal delivery or 96 hours following a cesarean section delivery.

Pre and Postnatal Office Visit

CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Exclusions: Covered services do not include vision services, except as otherwise specifically provided in the Contract, including but not limited to pleoptic training, orthoptic training that is not for convergence insufficiency, eyeglasses, contact lenses, and the examination for fitting of these items. Covered services do not include services and materials not meeting accepted standards of optometric practice.
Benefit Explanation: Covered services are limited to 1 routine eye exam per Calendar Year.

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered

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