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	Medicare Advantage Connect PPO	Medicare Advantage Access PPO
	When in- and out-of-network costs are applicable, costs are listed as follows: (In-Network/Out-of-Network)
Monthly Premium n/a	$0	$0	$31
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.	$6,200	$5,950 in-network $8,950 out-of-network	$5,900 in-network $8,950 out-of-network
Primary Care Doctor Visits* This is your personally selected Physician to help guide your care.	$10	$10 in-network $15 out-of-network	$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+	$420 per day for days 1-4 $0 per day for days 5+
Outpatient Hospital Surgery	$395 per day	$395 per day	$395 per day
Urgent Care	$60	$60	$60
Emergency Care	$95	$95	$95
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 21-51: $196 Days 52-100: $0	In-Network Days 1-20: $0 Days 21-50: $196 Days 51-100: $0 Out-of-Network Days 1-20: $0 Days 21-65: $196 Days 66-100: $0	In-Network Days 1-20: $0 Days 21-50: $196 Days 51-100: $0 Out-of-Network Days 1-20: $0 Days 21-65: $196 Days 66-100: $0
Routine Eye Exam Exam to diagnose diseases and conditions of the eye.	$10	$10	$0
Routine Hearing Exam Exam to diagnose hearing and balance problems.	$10	$0	$0
Over-the-Counter Allowance	$25 per quarter	$40 per quarter	$40 per quarter
Dental Maximum Reimbursement*	$650	$1,000	$1,000
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, 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			Medicare Advantage Connect PPO			Medicare Advantage Access PPO
	Rx Deductible	Copayment/Coinsurance		Rx Deductible	Copayment/Coinsurance		Rx Deductible	Copayment/Coinsurance
	Rx Deductible	30-day supply: In-network pharmacy	90-day supply: Mail order	Rx Deductible	30-day supply: In-network pharmacy	90-day supply: Mail order	Rx Deductible	30-day supply: In-network pharmacy	90-day supply: Mail order
Tier 1 (Preferred Generic)	$0	$4	$0	$0	$0	$0	$0	$0	$0
Tier 2 (Generic)	$0	$14	$0	$0	$14	$0	$0	$14	$0
Tier 3 (Preferred Generic)	$250	$47	$141	$175	$47	$141	$100	$47	$141
Tier 4 (Non-preferred brand)		$100	$300		$100	$300		$100	$300
Tier 5 (Specialty tier)		28%	N/A		30%	N/A		31%	N/A

Individual Plan Information

Group Plan Information

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