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

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

https://Medicare.NebraskaBlue.com

Plan Link

https://Medicare.NebraskaBlue.com

Medical Benefits

Doctor Services

Primary doctor visit

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

Specialist visit

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

Tests, labs, & imaging

Diagnostic tests & procedures

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

Lab services

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

Diagnostic radiology services (like MRI)

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

Outpatient x-rays

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

Emergency care

$90 copay per visit (always covered)

Urgent care

$65 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage

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

Outpatient hospital coverage

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

Ground ambulance

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

Therapy services

Occupational therapy visit

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

Physical therapy & speech & language therapy visit

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

Mental health services

Outpatient group therapy with a psychiatrist

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

Outpatient individual therapy with a psychiatrist

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

Outpatient group therapy visit

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

Outpatient individual therapy visit

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

Opioid treatment services

Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)

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

Prosthetics (like braces, artificial limbs)

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

Diabetes supplies

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

Tiers	Initial coverage phase	Gap coverage phase	Catastrophic coverage phase
Preferred Generic	$12.00 copay	Generic drugs : 25% Brand-name drugs : 25%	Generic drugs : $3.70 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 Tier	31%

Part B Drugs

Chemotherapy drugs

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

Other Part B drugs

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

Extra Benefits

Hearing

Hearing exam

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

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: 50% coinsurance

Contact lenses

In-network: $0 copay
Out-of-network: 50% coinsurance

Eyeglasses (frames & lenses)

Not covered

Eyeglass frames (only)

In-network: $0 copay
Out-of-network: 50% coinsurance

Eyeglass lenses (only)

In-network: $0 copay
Out-of-network: 50% coinsurance

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

Limited coverage

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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