SelectBlue Plus Three-Tier Options

SelectBlue Plus
Three-Tier Options
PLAN OPTIONS
Health Plans for Employer Groups
With 2-50 Employees
EF F ECTI VE J A NUARY 1, 20 14
Choose the best
BLUE FOR YOU!
If you own a small business, you already know the challenges
you face. It’s hard work. It’s a constant juggling act. You don’t
need us to tell you that.
What you do need from us is a way to offer your employees
health care coverage–affordably. Blue Cross and Blue Shield of
Nebraska has options to meet your needs. These unique threetier plans offer a variety of benefit designs at affordable costs
for groups in the Omaha community with 2 to 50 employees.
All SelectBlue Plus options meet all of the requirements
mandated by the Patient Protection and Affordable Care Act
(PPACA). So, with SelectBlue Plus, you can offer your employees qualified health plans that cover all the essential health
benefits, including pediatric dental and vision.
For specific information about your SelectBlue Plus options,
refer to pages 22-23 of this booklet.
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Small Group Three-Tier Options
The three tiers offer three levels of cost sharing:
COST SHARING
(deductible/copayment/
coinsurance)
NETWORK
CONSISTS OF
Select In-network
(Tier I)
Providers in the Select BlueChoice network Lowest
In-network
(Tier II)
All other NEtwork BLUE providers,
as well as BlueCard providers
Moderate
Out-of-network
(Tier III)
All non-contracting providers
Highest
Blue Cross and Blue Shield of
Nebraska has teamed with several
leading health care systems to offer
your employees a unique three-tier
plan design. This plan design uses
a select provider network called
Select BlueChoice. When a Select
BlueChoice provider is used, your
employees will receive Select
In-network (Tier I) benefits. These
benefits provide all the advantages
of In-network (Tier II) benefits, but
with the addition of lower deductibles, coinsurance, and copays.
You already know about health plans
with in-network and out-of-network
benefits. A three-tier plan is similar
to that, but a three-tier plan has an
additional tier (or level) that offers
the lowest cost sharing (or deductible, copayments, and coinsurance)
available in a plan. This tier is called
a Select In-network Tier.
providers in the Select In-network
Tier, members will receive all
the advantages of an in-network
provider, as well as pay the lowest
deductible, copayment and/or
coinsurance amounts available
under their plan.
Both Tier I and Tier II providers are
considered in-network. Members
may access any provider in any
of the tiers. However, if they use
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About the Select BlueChoice Network
These leading health care systems, and other providers, are in the Select BlueChoice network:
Children’s Hospital & Medical Center
and Children’s Physicians
Children’s Hospital & Medical Center is the
region’s leading provider of pediatric care. It
is the only full-service, pediatric health care
center in Nebraska offering hospital and
outpatient specialty care to children from
infancy through young adulthood. Children’s
operates the only Level II Pediatric Trauma
Center in the state and offers 24-hour,
in-house services by pediatric critical care
specialists. It is recognized as a 2012-13
Best Children’s Hospital by U.S. News
& World Report in cardiology and heart
surgery, and cancer.
The Nebraska Medical Center
The Nebraska Medical Center is Nebraska’s
largest health care facility with more than
5,700 employees and 1,350 physicians on
staff. Patients from all 50 states and
six continents come to The Nebraska
Medical Center for treatment. The
hospital is world-renowned in the major
service lines of oncology, solid organ
transplantation, cardiology, neurology and
trauma. It is also an international pioneer in
the treatment of lymphoma and leukemia.
The Nebraska Medical Center and its teaching partner, The University
of Nebraska Medical Center, are embarking on a cooperative effort to
build a new $370 million cancer center on campus.
Nebraska Orthopaedic Hospital
In the short time since opening in
2004, Nebraska Orthopaedic Hospital
has already established itself as a
leader in orthopaedics and health
care. Commitment to the complete
care and treatment of the patient, as
well as the dedication from physicians, administration and hospital
staff, has earned the hospital both
local and national recognition.
Nebraska Orthopaedic Hospital
is Joint Commission accredited
— receiving Disease Specific
Certification for both total hip
and total knee replacement.
U.S. News and World Report
named Nebraska Orthopaedic
Hospital a Top 50 Best Hospital
for Orthopaedics in 2010
and 2011.
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Top 50 Best
Orthopaedic
Hospital
Bellevue Medical Center
Methodist Hospital
Bellevue Medical Center is a full service, acute care hospital
offering emergency, intensive care, radiology, cardiology,
pulmonary, pathology, maternity, inpatient and outpatient
procedural, rehab and therapy, and patient care services.
Methodist Hospital was ranked second-best in Nebraska
by the recent U.S. News & World Report Best Hospitals
rankings.
For the third quarter in a row,
Bellevue Medical Center has been
recognized by the University
Healthcare Consortium (UHC) for
its outstanding quality measures.
3 quarters
in a row
Methodist Hospital
is a regular recipient
of the Consumer’s
Choice Award
Recognized for
outstanding
quality measures
In partnership with The Nebraska Medical Center, Bellevue
Medical Center recently announced the opening of a fullservice outpatient hematology/oncology clinic and infusion
center to better serve the residents of Bellevue, Sarpy
County and the surrounding area.
Nebraska Methodist Health System
Founded in 1982, Methodist Health System is the oldest not-forprofit health care system in the region and employs approximately
5,000 people. The Health System is a regionally recognized leader in
the delivery of consumer-preferred, high-quality services in cardiology, neurosurgery, women’s services, cancer care, gastroenterology,
orthopedics and comprehensive diagnostic services.
Methodist Health System is the parent organization for
•
•
•
•
Methodist Hospital
• Nebraska Methodist CollegeMethodist Women’s Hospital
The Josie Harper Campus
Jennie Edmundson Hospital
• Shared Service Systems
Methodist Physicians Clinic, Inc.
Methodist Women’s Hospital
Methodist Women’s Hospital is the region’s only hospital dedicated
to women’s health care—and delivers more babies than any other
hospital in Nebraska.
The Neonatal Intensive Care Unit at Methodist Women’s Hospital
takes care of more babies than any other NICU in the region.
Jennie Edmundson Hospital
Affiliated with Methodist Health System since 1994, Jennie
Edmundson Hospital in Council Bluffs was founded in 1886 by a
nondenominational group of women called the Faith Band. Jennie
Edmundson Hospital is a regional leader in wound care, emergency
angioplasty procedures, cancer care, obstetrics and newborn care,
sports medicine, occupational and behavioral health.
Fremont Area Medical Center and participating
local physicians
Fremont Area Medical Center (FAMC) is everything
a community hospital should be. And more. FAMC
is one of the leaders in the state in the number of da
Vinci™ robotic assisted surgical procedures performed
and is consistently ranked nationally for patient quality,
safety and patient satisfaction. Fremont Area Medical
Center has all private inpatient rooms, electronic patient
records, room service and much more.
SecureCare
SecureCare includes all the chiropractors in Nebraska
and offers chiropractic care, primary care, acupuncture,
and other noninvasive therapeutic services. In 2012,
this Independent Physician Association received the
nationally recognized URAC accreditation in provider
credentialing.
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access
50
IN ALL
S TAT E S
Provider networks
Statewide, nationwide and
around the world
A health plan is only as good as its
provider network. Whatever three-tier
health plan option you choose, your employees have access to a large network
of hospitals, doctors and other health
care providers. Select BlueChoice (Tier
I) offers a wide range of physicians and
hospitals through The Nebraska Medical
Center, Methodist Health System,
Children’s Hospital and Medical Center,
Fremont Area Medical Center, and
other facilities. Our NEtwork BLUE (Tier
II) network is made up of 93% of the
state’s doctors and 100% of Nebraska’s
non-governmental acute care hospitals.
That makes obtaining in-network care
easy and convenient.
In-network providers have agreed to
accept our benefit payment for covered
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services as payment in full, except for
any deductible, copays, coinsurance
amounts and charges for noncovered
services, which are the member’s
responsibility. That means Select
BlueChoice and NEtwork BLUE providers, under the terms of their contract
with us, can’t bill your employees for
amounts over our benefit allowance.
Out-of-network providers can bill
patients for amounts in excess of the
amount payable under the contract.
Select BlueChoice and NEtwork BLUE
providers also file claims for Blue Cross
and Blue Shield of Nebraska members,
meaning your employees have less
paperwork to worry about. And as an
additional time-saving convenience for
your employees, we send our benefit
payment directly to Select BlueChoice
and NEtwork BLUE providers.
Have employees living in other states?
Have employees with dependents
attending college out of state? The
BlueCard® Program makes obtaining
in-network care easy.
If your employees or their dependents
live or travel outside Nebraska, they
can still obtain covered services at the
in-network level through the BlueCard
Program.
To access benefits wherever they are,
all your employees have to do is use
hospitals and doctors in the local Blue
Cross and Blue Shield Plan’s BlueCard
PPO network. When they do, they
will also enjoy the discount and claim
filing agreements Blue Cross and Blue
Shield Plans across the country have
negotiated with the BlueCard network
hospitals and doctors in their area.
Emphasis on Health and Wellness
Blue Cross and Blue Shield of Nebraska (BCBSNE) is excited
to announce a new wellness program for our small group
members enrolled in SelectBlue Plus.
This program, administered by SimplyWell®,
helps members:
Keep their health care costs down
Learn new ways to live a healthier lifestyle
Learn ways to control stress
Best of all, this program is free to members…and they can
earn $50 in points* to spend at the SimplyWell online reward
store. Items in the store include jewelry, electronics, recreation, household items, music, movies, games, and more.
Participation is open to all BCBSNE members age 19 and older
who are covered by SelectBlue Plus.
This program is one more way we are helping our members
stay healthy and lower health care costs. If you have questions, please contact a member of your BCBSNE sales or
account service team, or call our Broker Services Line at
1-888-232-0942.
*Internal Revenue Service tax code specifies that certain
wellness program rewards offered to employees by employers
create tax liabilities to reward recipients. Therefore, the value
of the reward employees receive may result in employers
having to issue a tax document to employees for the rewards
employees earn in this program. At the end of the year,
BCBSNE will send a report to employers listing who earned
what rewards so employers can issue the tax document to
those employees.
SimplyWell, LLC is an independent company and does not
offer Blue Cross and Blue Shield of Nebraska products or
services. Blue Cross and Blue Shield of Nebraska has contracted with SimplyWell to administer the wellness program
mentioned above.
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SMALL CHANGES
CAN MAKE A
BIG
DIFFERENCE
Emphasis on Wellness
The lifestyle decisions employees make
regarding nutrition, weight, exercise,
smoking, seatbelt use, and more directly
impact their health care costs. Blue Cross
and Blue Shield of Nebraska offers
resources to help your employees make
positive lifestyle changes.
Blue Health Advantage
Our wellness and lifestyle management
program offers:
• Educational health and wellness
information
• Lifestyle management guides
• Personal health assessment tools
Health education
BlueHealth Advantage offers free health
brochures and lifestyle management
guides on a variety of topics, including
blood pressure and cholesterol, stress,
diabetes, heart health and healthy eating.
Programs
Know Your Numbers – This program
helps your employees understand
the numbers that impact their health,
including cholesterol, blood sugar, blood
pressure and more. Free promotional
materials are also available to you to
promote this program to your employees
at work.
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WalkingWorksSM – Regular exercise plays
a key role in staying healthy, and walking
is a great way to get that exercise. The
BlueHealth Advantage website provides
your employees with useful tips to
integrate walking into their daily routines,
and provides you with free tools to launch
a worksite walking campaign.
My 9 MonthsSM – Created by the March of
Dimes, My 9 Months is a special website
packed with the latest information about
preconception health and pregnancy in a
quick and easy-to-read format.
Self-service tools
• Body mass index calculator
• Personal health assessment
• Cost of smoking calculator
• Waist-to-hip ratio calculator
• Exercise log To check out all the valuable health
and wellness resources, go to
www.bluehealthadvantagene.com.
Blue365 is a national program that gives Blue members exclusive access to discounts and savings that
make it easier and more affordable to make healthy
choices. Members can explore special offerings from
leading national companies in these categories:
In conjunction with the Omaha World-Herald
newspaper, our health care and healthy living
information site provides comprehensive, reliable
health information specifically for Nebraskans.
To learn more, visit www.livewellnebraska.com.
Fitness
Healthy Eating
Personal Care
To learn more, visit www.nebraskablue.com/blue365.
Maternity Management Program
Our Maternity Management Program
is available to all of our group business.
This program is offered at no cost to the
employer or member. The program:
• Provides education and support during
prenatal and post-delivery stages
• Identifies for case management referral
members with potential for a high risk
pregnancy
• Rewards moms-to-be for participating in
the program
• Helps improve pregnancy outcomes and
reduce costs by preventing potential
complications and long-term health care
needs for mothers and babies
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Your Employees Can Manage Their
Health Care Whenever It’s Convenient
Online Member Services
The website that makes sense of your employees medical
bills and health care spending – all in one place.
Interactive Tools
Here your employees will find answers to questions like:
Your employees can help manage their health
care needs and costs with these online tools:
•
•
•
•
Have I met my deductible?
How much have I spent on health care this year?
How much might my knee surgery cost?
Which of my family members spent the most at the
pharmacy?
• How much did my insurance pay for my last doctor visit?
To sign up, employees:
AA Go to mynebraskablue.com
BB Select “Sign Up”
CC Complete the four easy steps
Your employees will need to enter their member ID number
found on their Blue Cross and Blue Shield of Nebraska
member ID card.
Your employees may then instantly access details about their
insurance plan and track their spending!
If they have questions about myblue, employees may call the
number on the back of their member ID card.
Coverage AdvisorSM
Helps employees understand which health
care services they are likely to need, and
then estimates the cost of those services.
Cost Estimator
Helps employees estimate medical costs
before they receive care. With this tool,
employees can find cost information for
many common medical conditions and
health care services, and compare physicians and facilities.
Review Your Doctor
Employees can write a review of their health
care experience and read other reviews of
doctors and hospitals.
MyPrime®
MyPrime is loaded with valuable information and interactive tools to help employees
manage their family’s prescription drug
purchases. This tool is from Blue Cross
and Blue Shield of Nebraska’s pharmacy
benefits manager, Prime Therapeutics, LLC.
With MyPrime, employees can find
• benefit information and personal prescription drug claim history
• a prescription drug list (also known as a
formulary)
• an Rx Nebraska participating pharmacy
locator
• a drug cost calculator
• a comparison of brand name and generic
drug costs
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Health Care Coverage
Calendar Year Deductible, Coinsurance, and
Out-of-Pocket Limits
Option 401
SelectBlue Plus option 401 requires satisfaction of an
embedded family deductible and out-of-pocket limit.
Out-of-Pocket Limit
Out-of-pocket limit is the maximum amount of cost-sharing
each covered person must pay in a calendar year before
covered services are payable at 100%. The out-of-pocket limit
includes deductible, coinsurance, and copayment amounts
for medical and pharmacy services. The out-of-pocket limit
does not include premium amounts, amounts over the allowable charge, charges for noncovered services, or penalties
for failure to comply with certification requirements or as
imposed under the Rx Nebraska Prescription Drug Program.
Embedded family deductible means if the employee
has family coverage, family members may combine their
covered expenses to satisfy the required calendar year family
deductible. However, no one family member contributes
more than the individual deductible amount to satisfy the
family’s deductible.
Note: The in-network and out-of-network deductible and
out-of-pocket limit amounts are separate and do not crossaccumulate.
After the required deductible has been satisfied, the
employee is responsible for paying a certain percentage of
covered charges, called “coinsurance,” until the out-of-pocket
limit has been reached. Under family coverage, the family
may combine their covered expenses to satisfy the required
embedded family out-of-pocket limit. No one family
member contributes more than the individual out-of-pocket
limit to satisfy the family’s out-of-pocket limit.
The additional pediatric orthodontic out-of-pocket
limit applies to all SelectBlue Plus options. This amount,
in addition to the out-of-pocket limit (not to exceed $6,350
Individual/$12,700 Family), must be satisfied before covered
pediatric orthodontic services are payable at 100%. On
plan options with aggregate out-of-pocket limits, the family
amount must be satisfied before services are payable at
100%. Please see the Schedule of Benefits Summary for
more information.
Note: Copay amounts for medical services and prescription
drugs do not apply toward the calendar year deductible.
Options 402 and 403
SelectBlue Plus options 402 and 403 require satisfaction of
an aggregate family deductible and out-of-pocket limit.
Aggregate family deductible means if the employee has
family coverage, the entire family deductible must be met
prior to any benefits becoming available. Family members
may combine their covered expenses to satisfy the required
family deductible. After the required deductible has been
satisfied, the employee is responsible for paying a certain
percentage of covered charges, called “coinsurance,” until
the out-of-pocket limit has been reached. Under family
membership, the entire aggregate family out-of-pocket
limit must be met before covered services are paid at 100%.
Family members may combine their covered expenses to
satisfy the required out-of-pocket limit.
Additional Pediatric Orthodontic
Out-of-pocket Limit
Standardized Metallic Plans
We are required to offer plans that meet certain actuarial
value requirements.
Actuarial value (AV) represents the amount the insurer pays
for an average claim. For example, if a plan has an AV of 70
percent, on average a member could expect to be responsible for 30 percent of the costs of all covered benefits in
that plan.
The base level, or Bronze plan, is 60 percent actuarial value.
We also offer richer benefit packages, known as Silver and
Gold plans, as shown in the below chart.
Required AV Levels
BRONZE
SILVER
GOLD
60%
70%
80%
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Prescription Drug Coverage
Blue Cross and Blue Shield of Nebraska’s Four-Tier
Formulary Program helps control the impact skyrocketing
prescription drug costs can have on your group’s plan.
Benefits are based on Blue Cross and Blue Shield of
Nebraska’s drug formulary, which is a listing of medicines
divided into categories, or tiers. The deductible and copay/
coinsurance amount the employee must pay for each
30-day supply of a covered prescription drug depends on
what tier the medication is in*.
Tier 1
Tier 2
Tier 3
Tier 4
Generic drugs
Formulary brand name drugs
Nonformulary brand name drugs
Specialty drugs**
To review the drug formulary and specialty drug
lists online, go to the Member Services tab of
www.nebraskablue.com and select Pharmacy Tools,
then Prescription Drug List or Specialty Drug Benefits.
To use your group’s prescription drug benefits, the employee simply takes his or her Blue Cross and Blue Shield
of Nebraska member ID card and the prescription to an Rx
Nebraska participating pharmacy and pays the applicable
copay/deductible/coinsurance amount.
To locate participating Rx Nebraska pharmacies nationwide, call toll-free 1-877-800-0746 or go to the Member
Services tab of www.nebraskablue.com and select
MyPrime, then Find a Pharmacy.
If the prescription is filled at a nonparticipating pharmacy, or
if the employee does not present his or her card at a participating pharmacy, he or she will need to file an Rx Nebraska
claim. The member will be reimbursed the Reasonable
Allowance for the drug less the applicable deductible and
copay/coinsurance amount and a 25% penalty.
IMPORTANT
* Under SelectBlue Plus Options 402 and 403, benefits
for covered prescription drugs are subject to applicable deductible and coinsurance amounts.
** Specialty drugs must be purchased through a designated specialty pharmacy after two fills.
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Using the Mail Service Pharmacy Benefit
If members use the PrimeMail® Mail Service Pharmacy Program, they may order up to a 90-day supply
of a covered medication at one time (if allowed by their
prescription). The copay/coinsurance amounts shown in
the charts on pages 22-23 apply per 30-day supply.
Please note: If members order a 90-day supply they
should make sure the prescription is written for a 90-day
supply, not including refills. Members could pay more out
of pocket if the prescription isn’t written correctly.
Using the Extended Supply Network
Pharmacy Benefit
Blue Cross and Blue Shield of Nebraska offers our
Extended Supply Network (ESN) retail pharmacy benefit
to all SelectBlue Plus members. This benefit allows
members to get a 90-day supply of prescription medications at one time from a retail pharmacy (if allowed by
their prescription).* Non-ESN retail pharmacies are limited
to a 30-day supply.
Members on Gold Option 401 must pay three copays at
one time to purchase a 90-day supply.
Members on Silver Option 402 and Bronze Option 403
must pay the applicable deductible/coinsurance amounts
to purchase a 90-day supply.
Using the ESN retail pharmacy benefit for up to a 90-day
supply of medications means fewer trips to the pharmacy,
saving our members time.
A list of ESN retail pharmacies is available on the
mynebraskablue.com My Pharmacy link, or by calling our
Member Services Department at the number on the back
of your Blue Cross and Blue Shield of Nebraska member
ID card.
* Except for specialty drugs.
Here’s What’s Covered Under the
Rx Nebraska Plan:
• FDA-approved drugs requiring a doctor’s
prescription.
• Compound prescriptions with at least one
FDA-approved prescription ingredient.
• AIDS therapy drugs.
• Anti-rejection drugs.
• Dexedrine (through age 21).
• Retin-A, Differin and Azelex (through age 40).
• Covered diabetic supplies.
• Prescription and over-the-counter drugs to
treat nicotine addiction.
• Injectable medications, including insulin.
• Oral and transdermal contraceptives.
• Prescription vitamins, including prenatal
vitamins.
These Drugs Are Not Covered Under
The Rx Nebraska Plan:
• Diet or appetite suppressant drugs.
• Nutrition care, nutritional supplements,
FDA-exempt infant formulas, supplies or other
nutritional substances (including Neocate,
Vivonex and other over-the-counter nutritional
substances).
• Drugs for treatment of infertility.
• Cosmetic alteration drugs, including health
and beauty aids (e.g. Vaniqa, Propecia and
Renova).
• Non-prescription and over-the-counter drugs.
• Erectile dysfunction agents (including Viagra,
Caverject, Muse, Cialis, Levitra and Alprostadil).
• A prescription medication purchased in a foreign
country, unless the covered person is living in
another country, or has an emergency medical
condition while traveling in that country.
• Non-sedating antihistamines or antihistamine
decongestant combination.
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COMMITTED
TO PROMOTING
QUALITY
CARE
SAFETY
AND PATIENT
Prescription Drug
Preauthorization Program
As part of our efforts to address the
serious issue of escalating costs and
continue to provide your employees
with access to quality and cost-effective
pharmacy care, Blue Cross and Blue
Shield of Nebraska requires that
benefits for certain prescription drugs
be preauthorized.
Gastroprotective NSAIDs
Proton Pump Inhibitors (PPIs)
This program manages the use of costly
gastroprotective NSAIDs used to treat
inflammation and reduce pain. These
drugs work the same as drugs such as
naproxen and ibuprofen.
PPIs are used to help reduce stomach
acid and provide relief from the symptoms of heartburn, ulcers and gastroesophageal reflux disease (GERD).
Patients whose medical history and current medical condition do not indicate
that use of a gastroprotective NSAID
is required need to try a traditional
NSAID first. Benefits for gastroprotective
NSAIDs will be available if the patient’s
medical condition warrants it.
Note: For a list of additional medications requiring preauthorization,
please go to www.nebraskablue.com. Select Member Services,
Pharmacy Tools, and then Prescription Drug List.
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For benefits to be considered for the
formulary brand medication Nexium,
members must first use a prescription
generic formulary PPI. For benefits to
be considered for a non-formulary PPI,
members must first use three formulary
PPIs. Benefits for generic formulary
PPIs do not require preauthorization.
Certification Requirements
Inpatient Hospital & Long Term Acute Care Benefits
Blue Cross and Blue Shield of Nebraska must be notified
of all medical/surgical inpatient hospital admissions. This
enables us to coordinate discharge planning, case management and disease management services with the patient’s
providers. If the patient is hospitalized in a contracting
Select BlueChoice or NEtwork BLUE hospital in Nebraska,
notification will be provided by the hospital.
Benefits are available for (but not limited to) the following
covered services:
If the patient is hospitalized in an out-of-network hospital
in Nebraska or is admitted to an inpatient facility in another
state, Blue Cross and Blue Shield of Nebraska must be
notified.
• FDA-approved drugs, intravenous solutions and vaccines
administered in the hospital.
Benefits must be precertified for the following inpatient
care, regardless of where the care is received, in or out of
network (including, but not limited to):
• Radiology, pathology and radiation therapy.
• Physical rehabilitation
• Long term acute care
• Skilled nursing facility care
When possible, certification should be completed prior to
the inpatient admission. Benefits for services that are not
medically necessary will be denied.
• Semiprivate room; cardiac and intensive care units;
treatment rooms and equipment.
• Anesthesia.
• Respiratory care.
• Chemotherapy.
• Physical, occupational and speech therapy.
• Inpatient physical rehabilitation, subject to benefit
precertification and certain requirements.
• Physician-ordered skilled nursing facility services, up to
60 days per calendar year; subject to medical necessity
criteria.
Outpatient Hospital Benefits
Preventive Care Benefits
Physician Benefits
Benefits for the services listed under
“Inpatient Hospital and Long Term
Acute Care Benefits” are also available
(subject to certain limitations) when
they are received in a hospital outpatient department, emergency room or
freestanding ambulatory surgical facility.
In addition, benefits for outpatient
cardiac and pulmonary rehabilitation are
available, subject to preauthorization
requirements and medical criteria.
Preventive care benefits are available
under all three-tier options. When a
network provider is used, benefits
are paid at 100% of the allowable
charge (deductible and coinsurance are
waived).
Benefits are available for (but not limited
to) the following covered services:
Benefits are available for (but not limited
to) the following covered services:
• Radiation therapy and chemotherapy
• Office visits and periodic exams to
determine physical development
• Pathology/lab
The Allowable Charge
• Mammograms and Pap smears
Payment is based on the allowable
charge for a covered service. Generally, the allowable charge for services
by in-network providers will be the
contracted amount. The allowable
charge for services by out-of-network
providers will generally be the lesser
of the billed charge or the Reasonable
Allowance for the service.
• Immunizations (including pediatric*)
• Colorectal cancer screenings and
related services
• Surgery and surgical assistance (for
specified procedures)
• Anesthesia
• Radiology and pathology, including
tissue exams
• Physician home, office and outpatient
visits for the diagnosis and treatment
of an illness or injury
• FDA-approved drugs
• Consultation
• Hearing
* Deductible (if applicable) is waived for
out-of-network pediatric immunizations.
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Primary Care Physician and Specialist Office
Services Copays (Applies to Gold Option 401 Only)
When a member goes to a network primary care physician
or specialist, he or she pays the plan’s designated copay
for office visit services. Only covered services and supplies
obtained in the physician’s office will be payable under the office services copay benefit. For office visits to out-of-network
primary care physicians and specialists, benefits for covered
services will be subject to the plan’s applicable deductible
and coinsurance amounts.
Covered services include:
• Physician office visits and consultations
• X-ray, lab and pathology services
Maternity coverage is included in all plan options and is available to employees, as well as covered spouses and dependent daughters. If the employee is covered under a single or
employee-spouse membership, benefits are available for the
newborn for 31 days from the date of birth. To continue the
newborn’s coverage beyond this time period, the employee
must request a change to single parent or family membership
within those 31 days and pay the additional premium.
Benefits are available for screening tests (including newborn/
infant hearing) and physician services for routine exams of a
newborn well infant while the baby is confined. All covered
charges incurred by a newborn from birth will be subject to
the baby’s calendar year deductible.
• Supplies used to treat the patient during the office visit
(excluding home medical equipment)
Obstetrical benefits include prenatal and postnatal care.
• Drugs administered during an office visit
Organ & Tissue Transplant Benefits
• Hearing and vision exams (non-routine/preventive)
Benefits are available for covered services associated with
medically necessary organ and tissue transplants, including
(but not limited to) liver, heart, lung, heart-lung, kidney,
pancreas, pancreas-kidney and cornea. Limited benefits
are also available for allogeneic/autologous bone marrow
transplants for the specific conditions listed in the contract.
• Allergy testing and injections
For purposes of this coverage, a “primary care physician“ is
a physician who has a majority of his or her practice in the
fields of internal or general medicine, obstetrics/gynecology,
general pediatrics or family practice. All other types of
physicians are considered specialists.
Oral Surgery
Benefits are available for (but not limited to) the following
covered services:
• Removal of tumors and cysts
• Incision and drainage of abscesses, and other nonsurgical
treatment of infections (not including periodontics or
endodontics)
• Reduction of a complete dislocation/fracture of the
temporomandibular joint of the jaw (TMJ), required as a
direct result of an accidental injury not related to eating,
biting, or chewing. Covered services must be provided
within 12 months of the injury
• Diagnostic or surgical procedures involving a bone or
joint of the face, neck or head, including osteotomies,
for the treatment of temporomandibular joint disorder or
craniomandibular disorder
• Treatment of natural teeth due to an accident which
occurs within 12 months of an injury not related to eating,
biting or chewing. Benefits are not available for orthodontics or dental implants
16
Maternity & Newborn Benefits
Home Health Aide, Skilled Nursing Care & Hospice
Benefits
The following covered services require benefit preauthorization. Limitations and exclusions apply.
Home health aide: When related to active medical treatment, benefits include personal services (e.g. bathing,
feeding and performing necessary household duties).
Benefits are subject to a 60-day per calendar year limit.
Skilled nursing care: Benefits are available for medically necessary physician-ordered care by a registered or
licensed practical nurse, provided in the home, up to eight
hours per day.
Hospice care: Benefits include Medicare-certified home
health aide services for a terminally ill patient, including
nursing services, respite care, medical social worker visits
and crisis care and bereavement counseling. Benefits for
inpatient hospice care are also available.
Other Covered Services
Noncovered Services
• Ambulance services
• Outpatient occupational therapy,
physical therapy and speech therapy,
up to a combined maximum of 45
sessions per calendar year
This brochure contains only a partial
listing of the limitations and exclusions
that apply to the three-tier health care
coverage. A more complete list may be
found in the master group contract.
• Inpatient and outpatient treatment
of mental illness and/or substance
abuse
No benefits are available for the
following:
• Services not covered by this contract
• Spinal manipulation treatments and
adjustments, up to 20 sessions per
calendar year
• External and surgically implantable
devices to improve hearing, including audient bone conductors, and
hearing aids and their fitting
• Rental/initial purchase (whichever
costs less) of medically necessary
home medical equipment ordered
by a doctor. Limited benefits are
available for the repair, maintenance
and adjustment of purchased covered
medical equipment
• Diabetes outpatient selfmanagement training and patient
management; podiatric appliances
• Services in accordance with the
Women’s Health and Cancer Rights
Act, which requires that a group
health plan providing medical and
surgical benefits for mastectomies
also provide benefits for breast
reconstruction, protheses and
treatment of physical complicationst
• Eye exercises or visual training
• Routine eye exam for members age
19 or older
• Eyeglasses or contact lenses for
members age 19 and older
• Infertility treatment and related services, including artificial insemination,
embryo transfer procedures, drug
and/or hormonal therapy, reversal of
voluntary sterilization, ultrasounds,
lab work and other testing done in
conjunction with fertility treatment
• Radial keratotomy or any
other procedures/alterations of the
refractive character of the cornea
to correct myopia, hyperopia and/or
astigmatism
• Services we consider to be investigative, not medically necessary,
experimental, cosmetic or obsolete
• Services, drugs, medical supplies,
devices or equipment that are
not cost effective compared to
established alternatives or that are
provided for the convenience or
personal use of the patient
• Services provided before the coverage effective date or after termination
• Services for illness or injury
sustained while performing military
service
• Services for injury/illness arising out
of or in the course of employment
• Charges for services which are
not within the provider’s scope of
practice
• Massage therapy
• Residential treatment programs for
treatment of mental illness and/or
substance abuse
• Treatment for weight reduction/
obesity, including surgical procedures
• Charges in excess of our contracted
amount
• Nutrition care, supplies, supplements
or other nutritional substances,
including Neocate, Vivonex and other
over-the-counter infant formulas and
supplements
• Charges made separately for
services, supplies and materials we
consider to be included within the
total charge payable
17
Pediatric Dental
Coverage
Coverage for pediatric dental services is
available for covered persons up to age
19 under all SelectBlue Plus plans.
Covered Services
Here is a partial list of pediatric dental
covered services. For a complete list
of covered services, please view the
master group contract.
Coverage A
Preventive and Diagnostic Dentistry
Under Coverage A, benefits are available for (but not limited to) the following
covered services:
• Two comprehensive and/or periodic
oral examinations per calendar year
• Consultation with a dental consultant
• Two prophylaxis, including cleaning,
scaling and polishing of teeth per
calendar year
• Two topical fluoride applications per
calendar year
• Dental X-rays
–– One full mouth or panorex series of
X-rays in five calendar years
–– Two sets of four supplemental
bitewing X-rays every calendar year
• Application of sealants to unrestored
permanent molar teeth, but not more
often than once per tooth every three
calendar years
• Space Maintainers, including
recementation. This does not include
removal of fixed space maintainers if
billed separately
• Pulp vitality tests
18
Coverage B
Maintenance and Simple Restorative
Dentistry
Under Coverage B, benefits are available for (but not limited to) the following
covered services:
Coverage D
Orthodontic Dentistry
All services related to orthodontic treatment must be certified to determine
medical necessity and are subject to a
24-month waiting period.
• Restorations of silver amalgam and/
or composite materials (if gold is
used as a filling material, reimbursement will be made as for amalgam)
• Cephalometric X-rays
Coverage C
Complex Restorative Dentistry
• Extractions related to orthodontia
Please see the master group contract
for a complete list of covered services
Oral surgery consisting of simple and
impacted extractions (not available for
orthodontic extractions), alveoloplasty,
surgical incision and drainage of dental
abscess, and tooth replantation
Periodontic services
• Treatment of diseases of gums and
supporting tooth structure
Endodontic services
• Treatment of diseases or injuries
of pulp chambers, root canals and
periapical tissue
• Panorex series X-rays, limited to not
more than one in five calendar years
• Surgical exposure to aid eruption
• Casts and models
• Initial and subsequent installations
of orthodontic appliances, and
orthodontic treatments. Benefits for
braces are limited to metal appliances only
• Oral/facial photographic images
• Special Provisions for Orthodontia
Covered Services and Treatment:
–– For all forms of orthodontic treatment,
if a provider bills a single charge for
the entire treatment at the start of
Coverage D Covered Services, payment will be made as set forth below,
unless otherwise agreed between
BCBSNE and the provider:
• Benefits for the initial banding will
be paid upon receipt of the claim
How to Locate Dental GRID
Dentists in Nebraska
By phone:
1-877-721-2583
On the web:
www.nebraskablue.com
• Covered charges will be divided
by the number of months in the
period of treatment, and the
appropriate amount will be paid
each month
–– Benefits for Coverage D Covered
Services are subject to a 24-month
waiting period. A change in plan
options under this contract will not
require a new 24-month waiting period provided that the covered person
maintained continuous coverage
under this contract. An interruption in
coverage, or a change from a group
plan to a non-group (individual) plan,
or the reverse, will require a new
24-month waiting period.
Note: The additional pediatric orthodontic out-of-pocket limit applies to all SelectBlue Plus options. This amount, in
addition to the out-of-pocket limit (not
to exceed $6,350 Individual/$12,700
Family), must be satisfied before
covered pediatric orthodontic services
are payable at 100%. On plan options
with aggregate out-of-pocket limits, the
family amount must be satisfied before
services are payable at 100%. Please
see the Schedule of Benefits Summary
for more information.
Exclusions and Limitations
In addition to the exclusions and
limitations stated in the contract, the
following benefits are not provided:
• Services that are not covered services
under the plan endorsement
• Dental services with respect to
congenital malformations (including,
but not limited to missing teeth) or
primarily for cosmetic or aesthetic
purposes, except as provided under
Coverage D. Gnathologic tests,
orthognathic surgery, osteoplasties,
osteotomies, LeFort procedures,
vestibuloplasties and stomatoplasties
are not covered services under this
endorsement
• Temporary crowns
• Caries susceptibility tests, bacteriologic studies and histopathologic
exams
• Magnetic resonance imaging and
computed tomography (CT) scans
• Services for orthodontic dentistry
except as identified under Coverage D
• Services for treatment of Temporomandibular (jaw) Joint
• Implants or any procedure associated
with the preparation for, maintenance
of or placement or removal of
implants, except as otherwise
indicated in the endorsement
• Oral pathology and laboratory
services, including but not limited to
biopsies
• Sealants for teeth other than
permanent molars
• Removal of dental cysts and tumors
(including biopsies and excisions of
mouth lesions)
• Excision of hyperplastic tissue
• Treatment of acute infection and oral
lesions
• Benefits will not be provided for
services, procedures or any supplies
which are considered to be for
cosmetic purposes, for personalization, or for any related services
• Oral surgery, including but not limited
to bone and osseous grafts, except
as provided by the endorsement
• Charges for services which are
paid or payable under the medical
provisions of the contract or under
another medical contract issued or
administered by us
Dental GRID is a network of GRID Dental Corporation, an independent, unlicensed entity that provides dental
network services on behalf of participating Blue plans such as Blue Cross and Blue Shield of Nebraska.
19
Pediatric Vision Coverage
Coverage for pediatric vision services is available for covered persons up to age 19 under all SelectBlue Plus plans.
PEDIATRIC VISION SERVICES
TIER I
Select Provider
TIER II
In-network Provider
TIER III
Out-of-network Provider
Vision Examination
(including refraction and dilation, limited to one exam
per calendar year)
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Eyeglass Frames/Lenses or Contacts
(limited to one set of frames and eyeglass lenses per
calendar year or one purchase of contact lenses, in lieu
of eyeglasses, per calendar year)
Deductible, then
50% Coinsurance
Deductible, then
50% Coinsurance
Tier II level of benefits
Deductible, then
50% Coinsurance
Deductible, then
50% Coinsurance
Tier II level of benefits
• Comprehensive low vision evaluation
(limited to one every 5 calendar years)
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
• Follow-up low vision care
(limited to four visits in any 5 calendar year period)
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible, then
50% Coinsurance
Deductible, then
50% Coinsurance
Tier II level of benefits
Medically Necessary Contact Lenses
(in lieu of eyeglasses, includes evaluation and fitting)
NOTE: Contact lenses, including the evaluation and
fitting require certification in excess of $600
Low Vision Services and Aids
• Low vision aids
NOTE: Low vision services and aids require
certification
Covered Services
Vision services received are subject
to the plan’s applicable deductible and
coinsurance, unless otherwise stated.
• One eye examination (contacts or
eyeglasses) every calendar year,
including refraction and dilation
• One eyeglass frame every calendar
year
• One pair of prescription eyeglass
lenses every calendar year
• One purchase for prescription
contact lenses in lieu of eyeglasses
every calendar year, including evaluation and fitting
• Medically necessary prescription
contact lenses, in lieu of eyeglasses
for certain conditions, subject to
certification for charges in excess
of $600. Contact lenses may be
determined to be medically necessary in the treatment of the following
conditions: keratoconus, pathological
myopia, aphakia, anisometropia,
aniseikonia, aniridia, corneal disorders, post-traumatic disorders, and
irregular astigmatism.
20
• Low vision services and aids as
follows:
–– One comprehensive low vision evaluation every five calendar years, subject
to certification
–– Four follow-up low vision care visits in
any five calendar year period, subject
to certification
–– Low vision aids such as, but not
limited to, high-power spectacles,
magnifiers and telescopes, subject to
certification. Benefits for a second or
subsequent purchase of an item for
low vision aids may be covered when:
• there is a significant change in the
covered person's condition;
• growth of a covered person;
• the item is irreparable or the cost
of repairs exceeds the expense of
purchasing a second item;
• the item is five or more years old
(unless replacement is medically
necessary prior to that time); or
• as otherwise determined to be
reasonable and necessary.
Types of Enrollment
Noncovered Services
Single Membership: Covers the employee only.
In addition to the exclusions and limitations stated in the contract, benefits are
not available for:
Family Membership: Covers the employee and eligible
dependents. This may include the employee’s spouse and/or
eligible dependents.
• Services and materials not meeting
accepted standards of optometric
practice
Eligible Dependent Children: The employee’s children
will be covered to the age of 26. Reaching age 26 will not
end the covered child’s coverage as long as the child is and
remains both incapable of self-sustaining employment, or of
returning to school as a full-time student, by reason of mental
or physical handicap and dependent upon the subscriber for
support and maintenance.
• Services and materials resulting from
failure to comply with professionally
prescribed treatment
• Office infection control charges
• Medical treatment of eye disease or
injury
• Visual therapy
• Replacement of lost or stolen eyewear
• Non-prescription lenses, including,
but not limited to, safety, athletic, or
sunglass lenses
• Two pairs of eyeglasses in lieu of
bifocals
• Vision prosthetic devices and related
services
• Insurance
• Deluxe, athletic, safety, and sunglass
frames
• Prescription lenses designed for safety,
athletic, or sunglass
• Color contact lenses
• Laser vision correction
• Services provided to any person 19
years of age or older
If you choose to buy insurance inside the SHOP,
your business may be eligible for tax credits, but
businesses must meet several criteria to qualify.
To qualify, your business must:
Have fewer than 25 full-time employees
How to Shop for and Buy a
SelectBlue Plus Option
Due to the Affordable Care Act (ACA or the new heath care
law), there are now two options for offering health insurance
to your employees:
AA You can buy health insurance that complies with the
health care law the same way as before the ACA –
through your agent/broker.
BB You can buy from the Small Business Options Program
(SHOP) Marketplace. In 2014, small business owners can
select only one plan from the SHOP to offer employees.
The federal government has said small businesses and
their employees will be able to choose from multiple
carriers and multiple plans in 2015.
What is the SHOP Marketplace?
The SHOP Marketplace, also known as “the SHOP,” is an
online option for small business owners to shop for and
purchase health care coverage for their employees. The SHOP
opens on October 1, 2013.
The SHOP was developed to give business owners a convenient
place to compare health care plans. The standardized “metallic”
plans, such as Gold, Silver, and Bronze, allow business owners
to compare plans with similar levels of coverage.
All three of our SelectBlue Plus options are available both
inside and outside the SHOP. This means you can buy any of
these options through your agent/broker or through the SHOP
Marketplace at healthcare.gov.
Pay average annual wages below $50,000
Contribute 50% or more toward your employees’
insurance premiums
21
Plan Options
HSA-Eligible
Deductible
Individual
Family
Type of deductible
Coinsurance
Hospital/medical/surgical/other
Out-of-pocket limit1
Individual
Family
Type of out-of-pocket limit
Preventive care
Preventive care services
Physician services
PCP office services
Specialist office services
Ambulance services
On and Off SHOP4 Marketplace
Out-of-network
(Tier III)
Select Network
(Tier I)
In-network
(Tier II)
Out-of-network
(Tier III)
$1,000
$2,000
$2,000
$4,000
Embedded
$4,000
$8,000
$1,500
$3,000
$2,000
$4,000
Aggregate
$4,000
$8,000
20%
30%
50%
20%
30%
50%
$2,000
$6,000
$4,500
$12,000
Embedded
$12,000
$24,000
$4,000
$8,000
$6,350
$12,700
Aggregate
$12,000
$24,000
0%
0%
Deductible and
Coinsurance
0%
0%
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Tier II Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Tier II Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Tier II Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Tier II Deductible and
Coinsurance
$10 copay
$10 copay
Copay + 25% penalty
$40 copay
$40 copay
Copay + 25% penalty
$80 copay
$80 copay
Copay + 25% penalty
$20 copay
$40 copay
$150 copay
Mental illness/substance abuse
Inpatient
Deductible and
Coinsurance
Outpatient
Deductible and
Coinsurance
Office services
$20 copay
Pharmacy benefits
Generic drugs
On and Off SHOP4 Marketplace
In-network
(Tier II)
Deductible and
Coinsurance
Emergency care services
Silver Option 402
Select Network
(Tier I)
Pregnancy and maternity services
Pre/Post natal care and delivery
Deductible and
Coinsurance
Emergency care
Urgent care facility services
$40 copay
Emergency care services
Gold Option 401
$150 copay
2
Formulary brand name drugs
Nonformulary brand name drugs
Specialty drugs
3
25% coinsurance with 25% coinsurance with
$75 min and $100 max $75 min and $100 max
Not covered
Tier I Deductible and Coinsurance
25% penalty applies for out-of-network
Tier I Deductible and Coinsurance
25% penalty applies for out-of-network
Tier I Deductible and Coinsurance
25% penalty applies for out-of-network
Tier I Deductible and
Tier I Deductible and
Not covered
Coinsurance
Coinsurance
1 The out-of-pocket limit includes deductible, coinsurance, and copayment amounts for medical and pharmacy services. An additional pediatric
orthodontic out-of-pocket limit applies to some plans. This amount, in addition to the out-of-pocket limit, must be satisfied before covered
pediatric orthodontic services are payable at 100%. Please see the Schedule of Benefits Summary for more information.
2 All pharmacy copays and/or deductible and coinsurance will accumulate to the Tier I out-of-pocket amounts.
3 Specialty drugs must be purchased through a designated specialty pharmacy after two fills.
4 SHOP means Small Business Health Options Program.
22
Benefit Chart Notes
HSA-Eligible
Bronze Option 403
On and Off SHOP4 Marketplace
Deductible
Individual
Family
Type of deductible
Coinsurance
Hospital/medical/surgical/other
Out-of-pocket limit1
Individual
Family
Type of out-of-pocket limit
Preventive care
Preventive care services
Physician services
PCP office services
Specialist office services
Select Network
(Tier I)
In-network
(Tier II)
Out-of-network
(Tier III)
$4,000
$8,000
$5,500
$11,000
Aggregate
$11,000
$22,000
20%
30%
50%
$6,000
$12,000
$6,350
$12,700
Aggregate
$15,000
$30,000
0%
0%
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
Deductible and
Coinsurance
• To be considered Select In-network (Tier
I), services must be provided by a Select
BlueChoice provider. To be considered Innetwork (Tier II), services must be provided
by a NEtwork BLUE provider.
• Copays do not apply toward the deductible
but are included in the out-of-pocket limit.
• Coinsurance is based on the allowable
charge for a covered service. Generally, the
allowable charge for services by in-network
providers will be the contracted amount.
The allowable charge for services by outof-network providers will generally be the
lesser of the billed charge or the reasonable
allowance for the service.
Pregnancy and maternity services
Pre/Post natal care and delivery
Deductible and
Deductible and
Deductible and
Coinsurance
Coinsurance
Coinsurance
Emergency care
Urgent care facility services
Deductible and
Deductible and
Deductible and
Coinsurance
Coinsurance
Coinsurance
Emergency care services
Deductible and
Deductible and
Tier II Deductible and
Coinsurance
Coinsurance
Coinsurance
Ambulance services
Deductible and
Deductible and
Deductible and
Coinsurance
Coinsurance
Coinsurance
Mental illness/substance abuse
Inpatient
Deductible and
Deductible and
Deductible and
Coinsurance
Coinsurance
Coinsurance
Outpatient
Deductible and
Deductible and
Deductible and
Coinsurance
Coinsurance
Coinsurance
Office services
Deductible and
Deductible and
Deductible and
Coinsurance
Coinsurance
Coinsurance
Emergency care services
Deductible and
Deductible and
Tier II Deductible and
Coinsurance
Coinsurance
Coinsurance
Pharmacy benefits2
Generic drugs
Tier I Deductible and Coinsurance
25% penalty applies for out-of-network
Formulary brand name drugs
Tier I Deductible and Coinsurance
25% penalty applies for out-of-network
Nonformulary brand name drugs
Tier I Deductible and Coinsurance
25% penalty applies for out-of-network
Specialty drugs3
Tier I Deductible and
Tier I Deductible and
Not covered
Coinsurance
Coinsurance
1 The out-of-pocket limit includes deductible, coinsurance, and copayment amounts for medical and pharmacy services. An additional pediatric
orthodontic out-of-pocket limit applies to some plans. This amount, in addition to the out-of-pocket limit, must be satisfied before covered
pediatric orthodontic services are payable at 100%. Please see the Schedule of Benefits Summary for more information.
2 All pharmacy copays and/or deductible and coinsurance will accumulate to the Tier I out-of-pocket amounts.
3 Specialty drugs must be purchased through a designated specialty pharmacy after two fills.
4 SHOP means Small Business Health Options Program.
23
This document is a brief overview of three-tier health plan options for groups with 2-50 employees. It is not a
contract. It is a general overview only. It does not provide all the details of the coverage, including benefits, limitations
and contract exclusions. In the event there are discrepancies between this document and the contract, the terms
and conditions of the contract will govern. For more information regarding benefits, limitations, exclusions and other
provisions, refer to the master group contract.
Blue Cross and Blue Shield of Nebraska is an independent
licensee of the Blue Cross and Blue Shield Association.
36-185 (07-16-13)