Blue Cross and Blue Shield of Nebraska
Group #: 101498
NEtwork BLUE Network
Pharmacy Network: Network C
Drug List: PDL 10 (Formerly "BCBSNE Standard Formulary")
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.
Benefits of an HSA
To help understand the benefits of a Health Savings Account, click here.
The information on this page is a partial description of benefits, limitations, exclusions, and other provisions of the group benefits provided by Woodmen of the World Life Insurance Society (WoodmenLife). If there is a difference between the information in this summary and the plan document for each plan, the plan documents govern. Eligibility requirements apply to each of the benefits offered, criteria may include employment status and/or individual qualifications. For more detailed information, refer to the Summary Plan Description of each plan. WoodmenLife may amend these plans at any time. The description of the plan is not a guarantee of benefits and should not be construed as such.
This is the Life is a registered service mark of Woodmen of the World Life Insurance Society.