Plan Overview

Simply Blue (PPO) is our most flexible plan with a $0 monthly premium, $0 medical and prescription drug deductibles, and a low maximum out-of-pocket of $4,800 you get the coverage you need with confidence for your budget.

Blue KC makes it flexible for you to use your plan as you decide. The new Blue Benefit Bucks works like a debit card so it’s simple to use and you have the power to spend it based on your personal needs.

The Simply Blue plan Blue Benefit Bucks card comes loaded with $1,000 for use on health-related services for dental, eyewear, hearing, and transportation. You can visit any dentist you like without the worry of a network. This plan’s flexibility gives you the power to decide where and how you’d like to use it. This card also comes loaded with a generous OTC allowance of $500 per year and we’ll add your healthy activity rewards1 on the same card as you earn them.

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Advantages Include

  • $0 monthly premium
  • $0 medical and prescription drug deductibles
  • $0 Primary care physician copay
  • $0 Tier 1 and Tier 2 Prescription Drugs, up to 100-day supply
  • $500 over-the-counter items allowance, every year
  • $1,000 Blue Benefit Bucks, flexible benefits for dental, hearing aids, eyewear and transportation combined
  • 40 hours per year for Member and Caregiver support for help to appointments or around the house
  • Low $4,800 annual out-of-pocket maximum in and out of network
  • SilverSneakers® fitness membership at no additional cost

You won't need to choose a Primary Care Physician (PCP) or get a referral to see a specialist. You have the freedom to go out-of-network with the same cost share to either in or out-of-network partners. You have worldwide emergency and urgent care coverage plus access to national BCBS network of providers.

To join, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. The Blue KC service area includes these counties in Kansas: Johnson and Wyandotte. And these counties in Missouri: Andrew, Bates, Buchanan, Cass, Clay, Clinton, Jackson, Johnson, Lafayette, Platte and Ray.

1Rewards for healthy activities may not be used for any benefit cost sharing.

Plan Benefits
At-A-Glance

Total Premium

$0

Blue National Network

Covered

Plan Deductible

$0

Maximum Out of Pocket (MOOP)

$4,800

Inpatient Services
Inpatient Hospital - Acute
In-Network

$300/day, Days 1-5
$0, Days 6-90*

Out-of-Network

$300/day, Days 1-5
$0, Days 6-90

Skilled Nursing Facility
In-Network

$0, Days 1-20
$188/day, Days 21-100

Out-of-Network

$0, Days 1-20
$188/day, Days 21-100

Emergency Care/Urgent Care
Emergency Care (Worldwide)
In-Network

$90

Out-of-Network

$90

Urgently Needed Care (Worldwide)
In-Network

$50

Out-of-Network

$50

Ambulance Services (Worldwide)
In-Network

$300

Out-of-Network

$300

Professional Services
PCP Visit
In-Network

$0

Out-of-Network

$0

Specialist Visit
In-Network

$35

Out-of-Network

$35

Telehealth
In-Network

$0

Out-of-Network

N/A

Diagnostic Testing Services
Diagnostic Procedures/Tests
In-Network

$0

Out-of-Network

$0

Lab Services
In-Network

$0

Out-of-Network

$0

X-Ray Services
In-Network

$0

Out-of-Network

$0

MRI/CT at physicians office or free standing
In-Network

$100

Out-of-Network

$100

MRI/CT at other facility
In-Network

$250

Out-of-Network

$250

Outpatient Services
Observation
In-Network

$300

Out-of-Network

$300

Outpatient Hospital & ASC (Minor surgical; other services)
In-Network

20%

Out-of-Network

20%

Surgery (Ambulatory Surgical Center)
In-Network

$250

Out-of-Network

$250

Surgery (Outpatient Hospital)
In-Network

$300

Out-of-Network

$300

Supplemental Services
Dental, Eyewear and Transportation

$1,000 Blue Benefit Bucks allowance for dental, hearing services, transportation and eyewear combined

Hearing and Hearing Aids

$1,000 Blue Benefit Bucks allowance for dental, hearing services, transportation and eyewear combined

Over-the-counter allowance

$500 per year

*After 90 days, our plan covers an unlimited number of additional days for an inpatient hospital stay at $0 copay.

Prescription Drug Benefits

Annual Deductible

$0

Preferred Generics (Tier 1)
30-day Supply

$0 copay

100-day Supply

$0 copay

Generics (Tier 2)
30-day Supply

$10 copay

100-day Supply

$0 copay

Preferred Brands (Tier 3)
30-day Supply

$47 copay

90-day Supply

$141 copay

Non-Preferred Drugs (Tier 4)
30-day Supply

$100 copay

90-day Supply

$300 copay

Specialty Drugs (Tier 5)
30-day Supply

33%

90-day Supply

N/A

Gap Coverage

Original Medicare Standard: 25% for all Tiers

$35 Insulin Program

Yes

We offer a 100-day mail order and retail drug benefit with a $0 copay for all Tier 1 and Tier 2 prescription drugs.

This information is not a complete description of benefits.

Sheri Blue KC Medicare Expert

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