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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.

Hospital & Medical Benefits

Click for more details Medicare Advantage Core HMO Metro / Central Medicare Advantage Access PPO
  When in- and out-of-network costs are applicable, costs are listed as follows:
Monthly Premium
$0 $26
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
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 in-network
$10,000 out-of-network
Primary Care Doctor Visits*  
This is your personally selected Physician to help guide your care.
$10/$5 $5 in-network
$15 out-of-network
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+
Outpatient Hospital Surgery $300 per day $295 per day
Urgent Care $65 $65
Emergency Care $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.
Days 1-20: $0
Days 21-53: $188
Days 54-100: $0
Days 1-20: $0
Days 21-44: $188
Days 45-100: $0
Days 1-20: $0
Days 21-73: $188
Days < 74-100: $0
Routine Eye Exam  
Exam to diagnose diseases and conditions of the eye.
$10 $0
Routine Hearing Exam  
Exam to diagnose hearing and balance problems.
$10 $0
Over-the-Counter Allowance $25 per quarter $50 per quarter
Dental Maximum Reimbursement* $650/$900 $1,350
Fitness Benefit  
Specialized fitness program designed for seniors.
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, Boone, Buffalo, Burt, Butler, Cedar, Chase, Clay, Colfax, Cuming, Custer, Dawson, Deuel, Dundy, Fillmore, Franklin, Frontier, Furnas, Gage, Garden, Garfield, Gosper, Grant, Greeley, Hall, Hamilton, Harlan, Hayes, Hitchcock, Holt, Hooker, Howard, Jefferson, Johnson, Kearney, Keith, Knox, Lincoln, Logan, Loup, Madison, McPherson, Merrick, Nance, Nemaha, Nuckolls, Pawnee, Perkins, Phelps, Pierce, Platte, Polk, Red Willow, Saline, Seward, Sherman, Stanton, Thayer, Thomas, Thurston, Valley, Wayne, Webster, Wheeler and York counties.

The Medicare Advantage Access PPO Plan is available in all 76 counties listed above.


Prescription Drug Benefits

  Medicare Advantage Core HMO Metro/Central Medicare Advantage Access PPO
Rx Deductible Copayment/Coinsurance Rx Deductible Copayment/Coinsurance
30-day supply: In-network pharmacy 90-day supply: Mail order 30-day supply: In-network pharmacy 90-day supply: Mail order
Tier 1 (Preferred Generic) $0 $3 $0 $0 $0 $0
Tier 2 (Generic) $0 $8 $0 $0 $8 $0
Tier 3 (Preferred Generic) $250 $37 $111 $100 $37 $111
Tier 4 (Non-preferred brand) $100 $300 $100 $300
Tier 5 (Specialty tier) 28% N/A 31% N/A


Individual Plan Information


Group Plan Information

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