Blue Cross and Blue Shield of Kansas, Inc

BlueCare EPO Gold

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $1,500.00 Family: $3000 Per Person: $1500
Combined Medical and Drug Out of Pocket Maximum	Individual: $4,950.00 Family: $9900 Per Person: $4950

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Specialist	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $65.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $300.00 Copay with deductible CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $25.00 CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Also covers surrogate mother if there is a petition to adopt within 90 days of birth.
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Also covers surrogate mother if there is a petition to adopt within 90 days of birth.

Vision

Routine Eye Exams for Children

CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered

Major Dental Care

Routine Dental Checkups for Children	CoPay: No Charge CoInsurance: No Charge Covered: Covered
Routine Dental Checkups for Adults	Covered: Not Covered