Missouri Western State University
Effective Date: 1/1/14
Health Benefit Plan Summary
This Benefit Summary provides only a highlight of the services covered by Blue Cross and Blue Shield of Kansas City.
www.BlueKC.com
Base Plan
Preferred-Care Blue
Plan Type
Plan Description
(Visit our website at www.BlueKC.com to receive a
complete listing of network hospitals and
physicians)
Deductible
Coinsurance (1)
A Preferred Provider Organization (PPO)
Members can receive services from any hospital or physician but receive greater benefits when they use the Preferred-Care Blue network.
Out-of-Pocket Maximum (2)
Applies to all Medical Cost-Sharing
Physician Office Visits
Lab Services
X-ray and Other Radiology Procedures
Routine Preventive Care
(Contract lists covered services)
Mammograms, Pap Smears and PSA tests
Routine Vision Care
Childhood Immunizations
Inpatient Hospital Services/Outpatient Surgery*
Inpatient Mental Illness/Substance Abuse*
Outpatient Mental Illness/Substance Abuse*
Emergency Room
Urgent Care
Electronic Physician Visit (e-visit)
Ambulance
Durable Medical Equipment*
Allergy Testing, Treatment, Injections
$1,000 per individual/$2,000 per family
Network: 80%
Non-network: 50%
Network: $4,100 individual/$8,200 family;
Non-network: $12,300 individual/$24,600 family
Deductible then coinsurance
Deductible then coinsurance
Network: Deductible then coinsurance (3)
Non-network: Deductible then coinsurance
Network Routine Services: 100%
Office Visit/Wellness Exam: 100%
Non-network: deductible then coinsurance
Unlimited calendar year maximum (applies to network and non-network)
Network Services: 100%
Office Visit: 100%
Non-network: Deductible then coinsurance
Network: Deductible then coinsurance
Non-network: Deductible then coinsurance
One exam per year
Network Services: 100%
Office Visit: 100%
Non-network: Deductible then coinsurance
Deductible then coinsurance (3)
Deductible then coinsurance (3)
Prior authorization required from New Directions
Deductible then coinsurance (3)
$100 copay then Deductible then 80%
(Copay waived if admitted to a network or non-network hospital)
Deductible then coinsurance
Network: $10 copay
Non-network: No Benefit
Deductible then 80%
Ground ambulance limited to Unlimited benefit maximum per use.
Deductible then coinsurance
Deductible then coinsurance
1
Portion of covered charges paid by BCBSKC after you satisfy your deductible and required copayments.
Total of deductible, coinsurance and copays members pay each year toward covered charges before BCBSKC pays 100% of benefits.
3
Diagnostic services performed at a Non-Participating Imaging Center inside Our Service Area are limited to $200 per day. Inpatient hospital services in a Non-Participating Hospital inside our service area are limited
to $200 maximum per day. Outpatient services at a Non-Participating Provider Hospital or at a Non-Participating Provider outpatient facility (including an ambulatory surgical center) inside our service area are
limited to $200 per day.
Right to opt out of elective abortion Your coverage does include elective pregnancy termination coverage. An enrollee who is a member of a group health plan with coverage for elective abortions has the right to exclude
and not pay for coverage for elective abortions if such coverage is contrary to his or her moral, ethical, or religious beliefs. Please call Customer Service to exclude coverage.
2
Log on to www.BlueKC.com for Provider Directories, claims status and much more!
Base Plan
Home Health Services*
Inpatient Hospice Facility*
Skilled Nursing Facility*
Outpatient Therapy*
(Speech, Hearing, Physical and Occupational)
Chiropractic Services*
Contraceptive devices, implants, injections and
elective sterilization
(includes insertion of devices)
Prescription Drugs*
Retail
Prescription Drugs:
Express Scripts: Mail order drug program
Lifetime Maximum
Dependent Coverage
Prior Authorization Penalty*
Pre-existing Exclusion Period
Portability
Late Enrollees
Detailed Benefit Information
Exclusions and Limitations
Customer Service
Blue KC 24 Hour Nurse Line
Preferred-Care Blue
Deductible then coinsurance
60 visit calendar year maximum
Deductible then coinsurance
14 day lifetime maximum
Deductible then coinsurance
30 day calendar year maximum
Deductible then coinsurance
Physical and Occupational:
Combined 40 visit calendar year maximum
Speech and Hearing:
20 visit calendar year maximum
Deductible then coinsurance
Network: Covered at 100%
Non-Network: Deductible then coinsurance
$10 copay for Tier 1 drug/contraceptives covered at 100%
$50 copay for Tier 2 brand drug;
$70 copay for Tier 3 brand drug
Non-network: 50% after copay
$20 copay for Tier 1 drug/contraceptives covered at 100%
$100 copay for Tier 2 brand drug;
$140 copay for Tier 3 brand drug
Unlimited
End of calendar year the children reach age 26
You are responsible for prior authorization for services received from non-network and out-of-area providers.
If prior authorization is not obtained for services which require prior authorization, you are responsible for the cost of the services.
None
Portability has been eliminated effective 1/1/2014 per ACA.
For employees or dependents applying after the eligibility period and not within a special enrollment period, coverage will become effective only on the group’s
anniversary date.
Call a Customer Service Representative or consult your booklet/certificate. The certificate will govern in all cases.
816-395-3558 or www.BlueKC.com
877-852-5422 24 hours a day … 365 days a year!
The covered services described in the Benefit Schedule are subject to the conditions, limitations and exclusions of the contract.
*Prior Authorization will be required for elective inpatient admissions, durable medical equipment (DME), infusion therapy and self injectables, organ and tissue transplants, some outpatient
surgeries and services, hearing therapy, prosthetics and appliances, mental health and chemical dependency, some outpatient prescriptions, skilled nursing facility, inpatient hospice facility, dental
implants and bone grafts, and chiropractic services received from a non-network chiropractor. This list of services is subject to change. Please refer to your contract for the current list of services,
which require Prior Authorization.
Right to opt out of elective abortion