Blue Cross and Blue Shield of Nebraska
Group #300190
Pharmacy Network: Network C
Drug List: PDL 10 (Formerly "BCBSNE Standard Formulary")
D/C = Deductible/Coinsurance
HSA | HRA | |||
Benefit Summary | In-Network | Out-of-Network | In-Network | Out-of-Network |
Deductible/Coinsurance | Aggregate | Aggregate | ||
Associate | $1,500 | $3,000 | $2,000 | $4,000 |
Associate Plus | $3,000 | $6,000 | $4,000 | $8,000 |
Coinsurance | 25% | 40% | 30% | 50% |
Out-of-Pocket Maximum (includes Deductible, Coinsurance and Copays) | ||||
Associate | $3,000 | $6,000 | $4,500 | $9,000 |
Associate Plus | $6,000 | $12,000 | $9,000 | $18,000 |
WoodmenLife HSA or HRA Contributions | ||||
Associate | $500 | $1,000 | ||
Associate Plus | $1,000 | $2,000 | ||
Office Visit | ||||
Primary Care | D/C | D/C | $30 Copay | D/C |
Specialist | D/C | D/C | D/C | D/C |
Other Office Visit Services | D/C | D/C | Included in Copay | D/C |
Preventive Care | 100% | D/C | 100% | D/C |
Virtual Doctor | D/C | D/C | $15 Fee | D/C |
Urgent and Emergency Care | ||||
Physician | D/C | D/C | $55 Copay | D/C |
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.
Benefits of an HSA
To help understand the benefits of a Health Savings Account, click here.