Blue Cross Blue Shield Nebraska MA Access (PPO)


Medicare Plan Details

2021 Plan
Monthly Premium
(select county for price)

 

by Blue Cross and Blue Shield of Nebraska
Additional Coverage
Hearing Vision Dental
Overall Government Star Rating
No Rating
out of 5 stars

State: Nebraska

Select your county to view the price for this plan

 


Plan Type

Medicare Advantage (Part C) with Prescription Drug (Part D)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D

 

$26
$0
$26
$0
$6,900 In and Out-of-network
$4,500 In-network
No
Yes
Yes
Yes

Medical Benefits

Doctor Services

In-network: $5 copay per visit
Out-of-network: $15 copay per visit
In-network: $30 copay per visit
Out-of-network: $40 copay per visit

Tests, labs, & imaging

In-network: $20-350 copay
Out-of-network: $20-350 copay
In-network: $0 copay
Out-of-network: $20 copay
In-network: $100-350 copay
Out-of-network: $20-350 copay
In-network: $15-350 copay
Out-of-network: $20-350 copay
$90 copay per visit (always covered)
$65 copay per visit (always covered)

Hospital Services

In-network: $420 per day for days 1 through 4
$0 per day for days 5 through 90
Out-of-network: $420 per day for days 1 through 4
$0 per day for days 5 through 90
In-network: $350 copay per visit
Out-of-network: $350 copay per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$179 per day for days 21 through 46
$0 per day for days 47 through 100
Out-of-network: $0 per day for days 1 through 20
$179 per day for days 21 through 59
$0 per day for days 60 through 100

Preventive services

In-network: $0 copay
Out-of-network: $0 copay

Ambulance

In-network: $325 copay
Out-of-network: $325 copay

Therapy services

In-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay

Mental health services

In-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay

Opioid treatment services

Covered

Other services

In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
In-network: 0-20% coinsurance per item
Out-of-network: 0-20% coinsurance per item

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseGap coverage phaseCatastrophic coverage phase
Preferred Generic$12.00 copay


Generic drugs :
25%

Brand-name drugs :
25%


Generic drugs :
$3.70 copay or 5% (whichever costs more)

Brand-name drugs :
$9.20 copay or 5% (whichever costs more)

Generic$18.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug$100.00 copay
Specialty Tier31%

Part B Drugs

In-network: 20% coinsurance
Out-of-network: 20% coinsurance
In-network: 20% coinsurance
Out-of-network: 20% coinsurance

Extra Benefits

Hearing

In-network: $5-30 copay
Out-of-network: $0-65 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Preventive Dental

In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
Not covered
In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Not covered
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Vision

In-network: $0 copay
Out-of-network: 50% coinsurance
In-network: $0 copay
Out-of-network: 50% coinsurance
Not covered
In-network: $0 copay
Out-of-network: 50% coinsurance
In-network: $0 copay
Out-of-network: 50% coinsurance
Not covered

Other benefits

Limited coverage
Limited coverage
Not covered
Not covered
Not covered
Limited coverage
Limited coverage
No Rating
No Rating
No Rating
No Rating
No Rating
No Rating
No Rating
No Rating
No Rating
No Rating
No Rating

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