Blue Cross Blue Shield Nebraska MA Access (PPO)

Medicare Plan Details

2020 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

Monthly Premium

$26

Health Portion of Premium

Drug Portion of Premium

$26

Health Plan Deductible

Health Plan Max Out-of-Pocket

$6,900 In and Out-of-network
$4,500 In-network

Nationwide Coverage included

Hearing Coverage included

Yes

Vision Coverage included

Yes

Dental Coverage included

Yes

Doctor Lookup Link

http://medicare.nebraskablue.com

Plan Link

http://medicare.nebraskablue.com

Medical Benefits

Doctor Services

Primary doctor visit

In-network: $5 per visit
Out-of-network: $15 per visit

Specialist visit

In-network: $30 per visit
Out-of-network: $40 per visit

Tests, labs, & imaging

Diagnostic tests & procedures

In-network: $20-350
Out-of-network: $20-350

Lab services

In-network: $0 copay
Out-of-network: $20

Diagnostic radiology services (like MRI)

In-network: $100-350
Out-of-network: $20-350

Outpatient x-rays

In-network: $15-350
Out-of-network: $20-350

Emergency care

$90 per visit (always covered)

Urgent care

$55 per visit (always covered)

Hospital Services

Inpatient hospital coverage

In-network: $395 per day for days 1 through 4
$0 per day for days 5 through 90
Out-of-network: $395 per day for days 1 through 4
$0 per day for days 5 through 90

Outpatient hospital coverage

In-network: $350 per visit
Out-of-network: $350 per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$169 per day for days 21 through 48
$0 per day for days 49 through 100
Out-of-network: $0 per day for days 1 through 20
$169 per day for days 21 through 48
$0 per day for days 49 through 100

Preventive services

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

Ambulance

Ground ambulance

In-network: $250
Out-of-network: $250

Therapy services

Occupational therapy visit

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

Physical therapy & speech & language therapy visit

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

Mental health services

Outpatient group therapy with a psychiatrist

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

Outpatient individual therapy with a psychiatrist

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

Outpatient group therapy visit

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

Outpatient individual therapy visit

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

Opioid treatment services

Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)

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

Prosthetics (like braces, artificial limbs)

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

Diabetes supplies

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

Prescription Drug Benefits

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

Tiers	Initial coverage phase	Gap coverage phase	Catastrophic coverage phase
Preferred Generic	$12.00 copay	Generic drugs : 25% Brand-name drugs : 25%	Generic drugs : $3.60 copay or 5% (whichever costs more) Brand-name drugs : $8.95 copay or 5% (whichever costs more)
Generic	$18.00 copay
Preferred Brand	$47.00 copay
Non-Preferred Drug	45%
Specialty Tier	31%

Part B Drugs

Chemotherapy drugs

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

Other Part B drugs

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

Extra Benefits

Hearing

Hearing exam

In-network: $5-30
Out-of-network: $15-40

Fitting/evaluation

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

Hearing aids - All types

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

Preventive Dental

Oral exam

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

Cleaning

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

Fluoride treatment

Not covered

Dental x-rays

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

Comprehensive dental

Non-routine services

Not covered

Diagnostic services

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

Restorative services

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

Endodontics

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

Periodontics

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

Extractions

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

Prosthodontics, other oral/maxillofacial surgery, other services

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

Vision

Routine eye exam

In-network: $0 copay
Out-of-network: 40%

Contact lenses

In-network: $0 copay
Out-of-network: 40%

Eyeglasses (frames & lenses)

In-network: $0 copay
Out-of-network: 40%

Eyeglass frames (only)

In-network: $0 copay
Out-of-network: 40%

Eyeglass lenses (only)

In-network: $0 copay
Out-of-network: 40%

Upgrades

Not covered

Other benefits

Fitness benefit

Limited coverage

Over the counter drug benefits

Limited coverage

In-home support services

Not covered

Home and bathroom safety devices

Not covered

Meals for short duration

Not covered

Annual physical exams

Limited coverage

Telehealth

Not covered

Summary rating of health plan quality

No Rating

Staying healthy: screenings, tests, & vaccines

No Rating

Managing chronic (long term) conditions

No Rating

Member experience with health plan

No Rating

Member complaints & changes in the health plan's performance

No Rating

Health plan customer service

No Rating

Summary rating of drug plan quality

No Rating

Drug plan customer service

No Rating

Member complaints & changes in the drug plan's performance

No Rating

Member experience with the drug plan

No Rating

Drug safety & accuracy of drug pricing

No Rating

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