HMO and PPO Plan Options Available

With Medicare Advantage plans from Blue Cross and Blue Shield of Nebraska you'll have predictable, easy-to-budget costs for doctor office visits, prescription drugs and more. Each plan offers a different level of benefits and out-of-pocket cost, so you can choose the one that is best suited to your needs.

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Hospital & Medical Benefits

Click for more details	Medicare Advantage Core (HMO) Metro / Central	Medicare Advantage Access (PPO)	Medicare Advantage Choice (HMO-POS)
	When in- and out-of-network costs are applicable, costs are listed as follows: (In-Network/Out-of-Network)
Monthly Premium n/a	$0	$26	$44
Travel Coverage Travel coverage means if you travel outside of the state you will be covered similar to in-state in-network benefits.	Yes	Yes	Yes
Maximum Out-of-pocket Limit (In-network/Combined in- and out-of-network) Maximum out of pocket means the total amount you are responsible to pay for Medicare-covered services.	$6,250	$4,500 / $6,900	$5,700 / $6,700
Primary Care Doctor Visits* This is your personally selected Physician to help guide your care.	$10/$5	$5 / $15	$10
Acute Inpatient Hospital	$420 per day for days 1-4 $0 per day for days 5+	$420 per day for days 1-4 $0 per day for days 5+	$380 per day for days 1-4 $0 per day for days 55-100
Outpatient Hospital Surgery	$300 per day	$200 per day	$200 per day
Urgent Care	$55	$55	$55
Emergency Care	$90	$90	$90
Inpatient Skilled Nursing Facility These facilites have the staff and equipment to give skilled nursing care or rehab services, they could be part of a hospital or nursing home.	$0 per day for days 1-20 $184 per day for days 21-54 $0 per day for days 55-100	$0 per day for days 1-20 $169 per day for days 21-48 $0 per day for days 49+	$0 per day for days 1-20 $169 per day for days 21-55 $0 per day for days 56+
Routine Eye Exam Exam to diagnose diseases and conditions of the eye.	$10	$0 / 40% Coinsurance	$0
Routine Hearing Exam Exam to diagnose hearing and balance problems.	$10	$0	$0
Over-the-Counter Allowance	$25 per quarter	$50 per quarter	$25 per quarter
Dental Maximum Reimbursement*	$650/$900	$1,350	$700
Fitness Benefit Specialized fitness program designed for seniors.	SilverSneakers	SilverSneakers	SilverSneakers
Service Area	Blue Cross and Blue Shield of Nebraska Medicare Advantage Core HMO plans have been divided into Metro/Central regional areas. Metro region* includes Cass, Dodge, Douglas, Lancaster, Otoe, Sarpy, Saunders and Washington counties. Central region includes Adams, Antelope, Arthur, Blaine, Buffalo, Burt, Butler, Chase, Clay, Colfax, Cuming, Customer, Dawson, Fillmore, Franklin, Frontier, Furnas, Gage, Garfield, Gosper, Grant, Greely, Hall, Hamilton, Harlan, Hayes, Hitchcock, Hooker, Howard, Jefferson, Johnson, Kearney, Keith, Knox, Lincoln, Logan, Madison, McPherson, Merrick, Nance, Nemaha, Nuckolls, Pawnee, Perkins, Phelps, Pierce, Platte, Polk, Saline, Seward, Sherman, Stanton, Thayer, Thomas, Valley, Wayne, Webster, Wheeler and York counties. The Medicare Advantage Access PPO Plan is available in all 68 counties listed above.		Available in Burt, Butler, Cass, Colfax, Cuming, Dodge, Douglas, Gage, Lancaster, Otoe, Saline, Saunders, Sarpy, Seward and Washington counties.

Prescription Drug Benefits

	Medicare Advantage Core (HMO)			Medicare Advantage Access (PPO)			Medicare Advantage Choice (HMO-POS)
	30-day Retail Supply		90-day Mail Order	30-day Retail Supply		90-day Mail Order	30-day Retail Supply		90-day Mail Order
	Preferred Cost Sharing	Standard Cost Sharing	90-day Mail Order	Preferred Cost Sharing	Standard Cost Sharing	90-day Mail Order	Preferred Cost Sharing	Standard Cost Sharing	90-day Mail Order
Tier 1: Preferred Generic Drugs	$3	$14	$0	$0	$12	$0	$2	$12	$0
Tier 2: Generic Drugs	$8	$18	$0	$8	$18	$0	$8	$18	$0
Tier 3: Preferred Brand Drugs	$37	$47	$111	$37	$47	$111	$37	$47	$111
Tier 4: Non-Preferred Drugs	$100	$100	$300	$100	$100	$300	$100	$100	$300
Tier 5: Specialty Drugs	28%	28%	N/A	31%	31%	N/A	30%	30%	N/A

Individual Plan Information

Group Plan Information

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Understanding all the coverage options available may feel confusing. Download our Blue Cross and Blue Shield of Nebraska Medicare options guide to review different products that are available and learn more about important dates to remember.

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