D/C = Deductible/Coinsurance
|Out-of-Pocket Maximum (includes Deductible, Coinsurance and Copays)|
|WoodmenLife HSA or HRA Contributions|
|Primary Care||D/C||D/C||$30 Copay||D/C|
|Other Office Visit Services||D/C||D/C||Included in Copay||D/C|
|Virtual Doctor||D/C||D/C||$15 Fee||D/C|
|Urgent and Emergency Care|
|Other Urgent Care Services||D/C||D/C||Included in Copay||D/C|
|Emergency Care||D/C||Same as In-Network||$175 Copay + D/C||Same as In-Network|
|Prescription Drug Retail 30-day supply|
|Generic||D/C||In-Network + 25%||$15 Copay||In-Network + 25%|
|Formulary||D/C||In-Network + 25%||30%, $37.50 min to $150 max||In-Network + 25%|
|Non-Formulary||D/C||In-Network + 25%||30%, $62.50 min to $250 max||In-Network + 25%|
|Specialty||D/C||Not covered||30%, $75 min to $300 max||Not covered|
|Prescription Drug Retail 90-day supply|
|Generic||D/C||Not covered||$37.50 Copay||Not covered|
|Formulary||D/C||Not covered||30%, $93.75 min to $375 max||Not covered|
|Non-Formulary||D/C||Not covered||30%, $156.25 min to $625 max||Not covered|
Total health insurance cost, paid by you and WoodmenLife, is based on actual claims over the prior two years, projected claims, administrative expenses for the upcoming year, the plan and level of coverage you select, and your salary/earnings as of Sept. 30.
Visit Nebraskablue.com online or with your mobile device or tablet to access details including:
Benefits of an HSA
To help understand the benefits of a Health Savings Account, click here.
With your Blue Cross Blue Shield Nebraska health insurance, you have access to medical assistance services, doctors and hospitals around the world. Click here to search for doctors outside the U.S.
Preventive care services are covered at 100% when they are obtained from a network provider, as long as no diagnosis is made. Click here for recommended preventive services.
The services listed are general recommendations. Your doctor may recommend different frequency or timing based on your personal or family history