Download UNMC student insurance brochure online

STUDENTBLUE
Student Health Insurance from Blue Cross and Blue Shield of Nebraska
2016-2017 Academic Year
Health Insurance for Students of
University of Nebraska Kearney
University of Nebraska-Lincoln
University of Nebraska Medical Center
University of Nebraska Omaha
To millions of Americans, Blue Cross® and Blue Shield® represents
peace of mind when it’s needed the most. That’s because the Blue
Cross and Blue Shield brand represents the nation’s largest and
most experienced health care benefit companies.
The Blue Cross and Blue Shield organization is not one single
company, but rather a confederation of independent, communitybased Plans. Collectively, Blue Cross and Blue Shield Plans cover
100 million people - one-third of all Americans - in all 50 states, the
District of Columbia, and Puerto Rico.
Blue Cross got its start in Nebraska in 1939 as the Associated
Hospital Service of Nebraska. Nebraska Blue Shield—originally
called the Nebraska Surgical Plan—came along in 1944. The two
companies merged in 1974 to form Blue Cross and Blue Shield of
Nebraska. Today, Blue Cross and Blue Shield of Nebraska insures
or provides benefit administration for almost 667,000 people.
We’ve been behind our members for more than 75 years … and
we’ll be behind you in whatever lies ahead.
This brochure provides information about StudentBlue, the student
health insurance plan offered by your university. If you have any
questions, please contact your campus insurance representative.
We appreciate the opportunity to serve your health plan needs.
Sincerely,
Steven S. Martin
Chief Executive Officer
Blue Cross and Blue Shield of Nebraska
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Schedule of Benefits Summary
HEALTH PLAN
Payment for Services
In-network
Out-of-network
Deductible (Embedded)
Individual
$500
$1,000
Family
$1,000
$2,000
Embedded deductible means if you have individual (student only) coverage, you only
need to pay the individual deductible and out-of-pocket limit amounts. If you have family
coverage, your family members’ covered expenses are combined to satisfy the required
family amounts, but no one family member must satisfy more than the individual amount.
Coinsurance
Covered person pays
20%
50%
Plan pays
80%
50%
Out-of-pocket limit (Embedded) (includes deductible, coinsurance, and copays)
Individual
$2,200
$4,400
Family
$4,400
$8,800
Once the annual out-of-pocket limit is reached, most covered services are payable by the
plan at 100% for the rest of the benefit year. In-network and out-of-network deductible and
out-of-pocket limits cross accumulate. All other limits (days, visits, sessions, dollar amounts,
etc.) do cross accumulate between in-network and out-of-network, unless noted differently.
Covered Services – Illness or Injury
In-network
Covered Services are reimbursed based on the Allowable Charge. Blue Cross and Blue Shield of Nebraska
In-network Providers have agreed to accept the benefit
payment as payment in full, not including Deductible, Coinsurance and/or Copayment amounts and any
charges for non-covered services, which are the Covered
Person’s responsibility. That means In-network providers,
under the terms of their contract with Blue Cross and
Blue Shield, can’t bill for amounts over the Contracted
Amount. Out-of-network Providers can bill for amounts
over the Out-of-network Allowance.
Covered Services provided by the University Student
Health Clinics at UNK, UNL, UNO and UNMC will be
covered with no cost-share to members, except as
shown under the Prescription Drugs section.
Out-of-network
Physician Office
Primary Care Physician Office Services
$20 Copay
Deductible and Coinsurance
Specialist Physician Office Services
$30 Copay
Deductible and Coinsurance
Primary Care Physician benefits include the office visit provided by a physician who has a majority of his or her
practice in internal or general medicine, obstetrics/gynecology, general pediatrics or family practice. A Certified
physician assistant and a Certified nurse practitioner are covered in the same manner as a Primary Care Physician.
Specialist Physician benefits include the office visits provided by a physician who is not a Primary Care Physician.
Physician Professional Services (Outpatient and Inpatient Services)
Physician Professional Services
Deductible and Coinsurance
Deductible and Coinsurance
Urgent Care Facility Services (a single Copay applies to each urgent care visit)
$75 Copay
Deductible and Coinsurance
Emergency Care Services (Services received in a Hospital emergency room setting)
Facility
$300 Copay then Deductible
In-network level of benefits
and Coinsurance
Professional Services
Deductible and Coinsurance
In-network level of benefits
Copayment is waived if admitted to the hospital within 24 hours for the same diagnosis)
Outpatient Hospital or Facility Services
Deductible and Coinsurance
Deductible and Coinsurance
Inpatient Hospital or Facility Services
Deductible and Coinsurance
Deductible and Coinsurance
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Schedule of Benefits Summary
HEALTH PLAN
Preventive Services
Preventive Services
Affordable Care Act (ACA) required preventive services (may be subject to
limits that include, but are not limited to, age, gender, and frequency)
ACA required covered preventive services (outside of limits)
Other covered preventive services not required by ACA, such as:
•Laboratory tests as specified by Us, including urinalysis and complete
blood count; prostate cancer screening (PSA) and hearing exams
•All other laboratory tests; radiology, cardiac stress tests; EKG; pulmonary
function and other screenings and services
Immunizations
Pediatric (up to age 7)
Age 7 and older
Related to an illness
Pre-classroom Enrollment
In-network
Out-of-network
Plan Pays 100%
Deductible and Coinsurance
Plan Pays 100%
Deductible and Coinsurance
Plan Pays 100%
Deductible and Coinsurance
Same as any other illness
Same as any other illness
Plan Pays 100%
Plan Pays 100%
Same as any other illness
Coinsurance
Deductible and Coinsurance
Same as any other illness
In-network
Out-of-network
Immunizations and Testing (Services required by University prior to admission)
Plan Pays 100%
Plan Pays 100%
Mental Illness and/or Substance Dependence
and Abuse Covered Services
Out-of-network
In-network
Inpatient Services
Deductible and Coinsurance
Outpatient Services
Office Services
$20 copay
All Other Outpatient Items & Services
Deductible and Coinsurance
Emergency Care Services (Services received in a Hospital emergency room setting)
Facilty
$300 Copay then Deductible
and Coinsurance
Professional Services
Deductible and Coinsurance
Copayment is waived if admitted to the hospital within 24 hours for the same diagnosis)
Deductible and Coinsurance
Transgender Assignment/Reassignment
Out-of-network
In-network
Deductible and Coinsurance
Deductible and Coinsurance
In-network level of benefits
In-network level of benefits
Inpatient Services
Deductible and Coinsurance
Outpatient Services
Office Services
$20 Copay
All Other Outpatient Items & Services
Deductible and Coinsurance
Emergency Care Services (Services received in a Hospital emergency room setting)
Facilty
$300 Copay then Deductible
and Coinsurance
Professional Services
Deductible and Coinsurance
Copayment is waived if admitted to the hospital within 24 hours for the same diagnosis)
Note: Surgery and related Covered Services limited to $75,000 while covered
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Deductible and Coinsurance
Deductible and Coinsurance
Deductible and Coinsurance
In-network level of benefits
In-network level of benefits
Schedule of Benefits Summary
HEALTH PLAN
Other Covered Services – Illness or Injury
In-network
Out-of-network
Accident Related Care (Supplemental Benefit)
Plan Pays 100%
In-network level of benefits
Limited to $2,000 per person per Benefit Year, for charges in excess of this amount see the applicable service category
Ambulance (to the nearest facility for appropriate care)
Ground Ambulance
Deductible and Coinsurance
In-network level of benefits
Air Ambulance
Deductible and Coinsurance
Deductible and Coinsurance
(In-network level of benefits
if due to an emergency
Durable Medical Equipment
Deductible and Coinsurance
Deductible and Coinsurance
Home Health Care
Skilled Nursing Care (limited to 8 hours per day
Deductible and Coinsurance
Deductible and Coinsurance
Home Health Aide (limited to 60 days per Benefit Year)
Deductible and Coinsurance
Deductible and Coinsurance
Respiratory Care (limited to 60 days per Benefit Year)
Deductible and Coinsurance
Deductible and Coinsurance
Hospice Services
Deductible and Coinsurance
Deductible and Coinsurance
Independent Laboratory
Diagnostic
Plan Pays 100%
In-network level of benefits
Preventive
Same as Preventive Services Same as Preventive Services
In-network level of benefits
In-network level of benefits
Intercollegiate Sports Injuries
Same as any other illness
Same as any other illness
Limited to UNK and UNO students and subject to $20,000 per person per Benefit Year
Pediatric Dental (up to age 19)
Preventive and Diagnostic
Deductible and Coinsurance
Deductible and Coinsurance
Maintenance and Simple Restorative
Deductible and Coinsurance
Deductible and Coinsurance
Complex Restorative
Deductible and Coinsurance
Deductible and Coinsurance
Orthodontic Services (24 month wait applies)
Deductible then Covered
Deductible then Covered
Person pays 70%
Person pays 70%
NOTE: Age and frequency limits apply
Pregnancy and Maternity Services (prenatal/postnatal care and delivery)
Deductible and Coinsurance
Deductible and Coinsurance
Skilled Nursing Facility (limited to 60 days per Benefit Year)
Deductible and Coinsurance
Deductible and Coinsurance
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Schedule of Benefits Summary
HEALTH PLAN
Other Covered Services – Illness or Injury
In-network
Out-of-network
$15 Copay
Not Covered
Deductible and Coinsurance
Deductible and Coinsurance
Deductible and Coinsurance
Deductible and Coinsurance
Deductible and Coinsurance
Deductible and Coinsurance
See Physician Office Services
See Physician Office Services
See Pediatric Vision Services
Section
Plan Pays 100% up to $50 per
Benefit Year then Not Covered
See Pediatric Vision Services
Section
Plan Pays 100% up to $50 per
Benefit Year then Not Covered
Deductible and Coinsurance
Deductible and Coinsurance
In-network
Out-of-network
Telehealth Services (by a designated Provider)
Temporomandibular and Craniomandibular Joint Disorder
Therapy & Manipulations
Physical, occupational or speech therapy services, chiropractic or
osteopathic physiotherapy (combined limit to 45 sessions per Benefit Year)
Chiropractic or osteopathic manipulative treatments or adjustments
(combined limit to 20 sessions per Benefit Year)
Vision Exams
Diagnostic (to diagnose an illness)
Preventive (routine exam including refraction):
•Pediatric (up to age 19)
•Adult (age 19 and over) limited to $50 per Benefit Year
All Other Covered Services
Pediatric Vision Services
Pediatric Vision Services are limited to Covered Persons up to age 19
Vision Examination (including refraction and dilation, limited to one exam per Benefit Year)
Deductible and Coinsurance
Deductible and Coinsurance
Eyeglass Frames/Lenses or Contacts
(limited to one set of frames and eyeglass lenses per Benefit Year or one purchase of Contact lenses per Benefit Year)
Lenses
Deductible then Covered
In-network level of benefits
Person pays 50%
Frames
Deductible then Covered
In-network level of benefits
Person pays 50%
Contact Lenses (including evaluation and fitting, when in lieu of eyeglasses)
Deductible then Covered
In-network level of benefits
Person pays 50%
Medically Necessary Contact Lenses (in lieu of eyeglasses, for specific conditions)
Deductible then Covered
In-network level of benefits
Person pays 50%
NOTE Certification required in excess of $600
Low Vision Services and Aids
Comprehensive low vision evaluation (limited to one every ( 5 ) Benefit Years) Deductible and Coinsurance
Deductible and Coinsurance
Follow-up low vision care (limited to four visits in any (5) Benefit Year period) Deductible and Coinsurance
Deductible and Coinsurance
Low vision aids
Deductible then Covered
In-network level of benefits
Person pays 50%
NOTE: Certification required for low vision Services and aids
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Schedule of Benefits Summary
HEALTH PLAN
UNL Health Center
Pharmacy
In-network
Generic drugs
$5 copay
$10 copay
Formulary brand name drugs
$30 copay
$40 copay
Non-formulary brand name drugs
$80 copay
$80 copay
Prescription Drug Plan
Out-of-network
Retail and mail order (per 30-day supply)
In-network level of benefits
+ 25% penalty
In-network level of benefits
+ 25% penalty
In-network level of benefits
+ 25% penalty
A 90-day supply is available at a retail Extended Supply Network pharmacy subject to three copays.
Specialty drugs
$100 copay
$100 copay
Specialty drugs must be purchased through a designated specialty pharmacy after two fills.
Contraceptives
Formulary - generic
Plan pays 100%
Plan pays 100%
Formulary - brand
Plan pays 100%
Plan pays 100%
Non-formulary - generic
$5 copay
$10 copay
Non-formulary - brand
$80 copay
$80 copay
Not covered
25% penalty
25% penalty
In-network level of benefits
+ 25% penalty
In-network level of benefits
+ 25% penalty
DENTAL PLAN
Dental Insurance
In-network
Deductible (Applies to Coverage B)
Individual
$50
Family
$100
Benefit year maximum benefit (Applies to Coverage A and B)
Benefit year maximum
$1,000
Coinsurance
Coverage A
0%
Coverage B - crowns (Plan pays 30%)
70%
Coverage B - all other covered services 20%
Coverage C
No coverage
Coverage D
No coverage
Out-of-network
$100
$200
$1,000
40%
70%
50%
No coverage
No coverage
Covered Services are reimbursed based on the Allowable Charge. Blue Cross and Blue Shield of Nebraska
In-Network Providers have agreed to accept the benefit
payment as payment in full, not including deductible,
coinsurance and/or copay amounts and any charges for
non-covered services, which are the Covered Person’s
responsibility. That means that In-Network providers,
under the terms of their contract with Blue Cross and
Blue Shield, can’t bill for amounts over the Contracted
Amount. Out-of-Network Providers can bill for amounts
over the Out-of-Network Allowance.
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Schedule of Benefits Summary
DENTAL PLAN
Below is a brief overview of the benefits within each of the coverage types.
Please refer to page 7 of this Schedule of Benefits Summary for your actual benefits.
Coverage For Dental Services
Coverage A – Preventive and Diagnostic
•Comprehensive and/or periodic oral exams (two every Benefit Year)
•Consultations
•Prophylaxis (cleaning, scaling and polishing) (two every Benefit Year)
•Topical Fluoride (two every Benefit Year for Covered Persons under
Age 16)
•Sealants (permanent first and second molar teeth) (one every four
Benefit Years for Covered Persons under Age 16)
•X-rays (intraoral, bitewing, occlusal, periapical, extraoral)
--Full mouth or panorex series (one every three Consecutive Benefit
Years)
--Supplemental bitewing
•(two sets of four every Benefit Year)
•Space Maintainers (for Covered Persons under Age 16)
•Pulp Vitality Test
•Fluoride Varnishes (two every Benefit Year)
•Periodontic cleanings (four every Benefit Year)
Coverage B – Maintenance, Simple Restorative, Oral Surgery, Periodontic, Endodontics
•Oral Surgery
•Endodontic Services (treatment of diseases or injuries of pulp
--Simple and impacted extractions
chambers, root canals and periapical tissue)
--Alveoplasty
--Pulp cap
--Removal of dental cysts and tumors
--Vital pulpotomy
--Surgical incision and drainage of dental abscess
--Root canal therapy (includes treatment plan, x-rays, clinical
--TMJ reduction (of a complete dislocation or fracture resulting from
procedures and follow up care)
an accidental injury and provided within 12 months of the injury)
--Apical curettage
--Tooth replantation
--Root resection and hemisection
--Excision of hyperplastic tissue
•General Anesthesia
•Periodontic Services (treatment of diseases of gums and supporting
•Restorations, except gold restorations
tooth structure)
•Palliative Treatment
--Gingivectomy and Gingival curettage
•Dry Socket Treatment
--Osseous surgery and graft
•Repair of Dentures, Bridges, Crowns and Cast Restoration
--Scaling and root planning
•Emergency Oral Examination
--Periodontal splinting
•Prefabricated crowns
--Mucogingivoplastic surgery
•Recement inlays and crowns
--Treatment of acute infection and oral lesions
•Temporary crown (within 72 hours of accident)
--Full mouth debridement
•Crowns (except as otherwise specifically identified – the Plan Pays 30%)
•Core Buildup
Coverage C – Complex Restorative Dentistry NOT COVERED
•Inlays when used as abutments for fixed bridgework
•Dentures – full and partial
•Installation of permanent bridges
•Denture Adjustments (after six months from date of installation)
•Cast post and core in addition to crown
•Denture Relining (one every 36 Consecutive Months)
•Abutment crowns
Coverage D – Orthodontic Dentistry NOT COVERED
•Cephalometric X-rays
•Orthodontic Appliances (initial and subsequent installations)
•Extractions
•Surgical exposure to aid eruption
•Casts and Models
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Coverage Effective Dates
University of Nebraska Medical Center
Program
Allied Health, PA1, PT1, PT2, PT3, Medical Nutrition Perfusion 5 & 6,
Cytotechnology, Medicine 1 & 2, Pharmacy 1, 2 & 3, Radiology, Oncology,
Nursing, Post MS, graduate, RSTE Medical Family Therapy
Accelerated Nursing
Clinical Lab Science
New 4th Year Pharmacy (4th Year Student enrolling in plan for first time)
PA 2
PA 3
Dental Program
Post Graduate Dental Certificate
Post Graduate
New 3rd & 4th Year Medical Student
Visiting Scholars/Miscellaneous
University of Nebraska - Kearney
Fall Semester: August 1, 2016 - December 31, 2016
Spring/Summer Semesters: January 1, 2017 - July 31, 2017
University of Nebraska - Lincoln
Fall Semester: August 1, 2016 - December 31, 2016
Spring/Summer Semesters: January 1, 2017 - July 31, 2017
Benefit Year
August 1, 2016 through July 31, 2017
May 1, 2016 through April 30,2017
May 1, 2016 through April 30, 2017
May 1, 2016 through April 30,2017
August 1, 2016 through July 31, 2017
July 1, 2016 through June 30, 2017
August 1, 2016 through July 31, 2017
July 1, 2016 through June 30, 2017
July 1, 2016 through June 30, 2017
July 1, 2016 through June 30, 2017
May 1, 2016 through April 30, 2017
Previously Enrolled Students with
Continuous Coverage
University of Nebraska - ALL CAMPUSES
The Benefit Year for previously enrolled students with
continuous coverage will be adjusted to be consistent
with the 2016/2017 academic year for the program in
which you are currently enrolled. Your Benefit Year will
continue to follow these dates as long as you elect to
have continuous coverage under the plan regardless of
a change in academic programs at the University.
University of Nebraska - College of Technical Agriculture
Fall Semester: August 1, 2016 - December 31, 2016
Spring/Summer Semesters: January 1, 2017 - July 31, 2017
University of Nebraska - Omaha
Fall Semester: August 1, 2016 - December 31, 2016
Spring/Summer Semesters: January 1, 2017 - July 31, 2017
Please note: This Schedule of Benefits Summary is intended to provide you with a brief overview of your benefits. It is not a contract and should not be
regarded as one. For more complete information about your plan, including benefits, exclusions and contract limitations, please refer to the master group
contract. In the event there are discrepancies between this document and the contract, the terms and conditions of the contract will govern.
9
CREATING A
FEARLESS
TOMORROW
10
How to Enroll
UNK
International students attending UNK are automatically enrolled in
StudentBlue. All other students are invited to enroll online for yourself
and your eligible dependents by visiting nebraskablue.com/studentblue
and selecting the appropriate link for your campus.
UNL
UNL graduate assistants and international students are automatically
enrolled in StudentBlue.
All other students are invited to enroll during open enrollment
via MyRED. After open enrollment, you must enroll by visiting
nebraskablue.com/studentblue and selecting the appropriate link for
your campus.
All UNL students may enroll their eligible dependents by visiting
nebraskablue.com/studentblue and selecting the appropriate link for
your school.
UNMC
All full-time UNMC students are automatically enrolled in
StudentBlue. Part-time UNMC students may enroll by visiting
nebraskablue.com/studentblue and selecting the appropriate link for
your campus. All students may enroll their eligible dependents by visiting
nebraskablue.com/studentblue and selecting the link for your school.
UNO
International students and graduate assistants attending UNO are
automatically enrolled in StudentBlue. Graduate assistants may waive
StudentBlue coverage through the MavLINK portal by the set deadline.
All other students are invited to enroll online for yourself and your
eligible dependents by visiting nebraskablue.com/studentblue and
selecting the appropriate link for your campus.
Dependent Eligibility
Covered students may enroll their eligible dependents. Eligible
dependents are the covered student’s spouse residing with the
covered student and/or the covered student’s children under age 26.
Dependents must be enrolled for the same period of coverage as
the covered student. All newborn children of the covered student
or covered spouse are automatically covered for injury or sickness
from the moment of birth for an initial period of 31 days. Adopted
children are covered for 31 days from the date of placement. Coverage
includes, but is not limited to, coverage for congenital anomalies.
Coverage may be continued beyond this 31-day period by paying
the additional cost to cover the child, and by enrolling the child via
nebraskablue.com/studentblue.
For help enrolling in the plan, or for questions regarding insurance
waivers, please contact Luanda Warren at Ascension Benefits &
Insurance Solutions at (800) 955-1991, ext. 7464.
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How to Waive Coverage
UNL and UNO Domestic Graduate Assistants
If you wish to waive StudentBlue coverage, you must
submit a waiver by visiting nebraskablue.com/studentblue and selecting the link for your school. You will be
redirected to a site administered by Ascension, the
waiver administrator.
International Students and International Graduate
Assistants
All international students are required to have health
insurance. If you wish to waive StudentBlue coverage,
you must have other coverage that meets the
requirements of the campus you attend as outlined below.
UNMC international students –
UNK international students –
• U.S.-based carrier
J1 Visa holders:
• $500 deductible or less
• U.S.-based carrier
• Unlimited medical maximum
• $500 deductible or less
• Meets or exceeds Affordable Care Act requirements
• $100,000 medical maximum or more
• Unlimited medical evacuation and repatriation of
remains
• $25,000 repatriation of remains maximum or more
UNL international students –
• U.S.-based carrier
• $500 deductible or less
• Unlimited medical maximum
• Meets or exceeds Affordable Care Act requirements
• Unlimited medical evacuation and repatriation of
remains
UNO international students –
• U.S.-based carrier
• $50,000 medical evacuation maximum or more
F1 Visa holders:
• $500 deductible or less
• $50,000 medical maximum or more
• $7,500 repatriation of remains maximum or more
• $10,000 medical evacuation maximum or more
If your other insurance meets the above requirements,
submit a waiver by visiting nebraskablue.com/studentblue
and selecting the appropriate link for your campus. You
will be redirected to a site administered by Ascension, the
waiver administrator.
• $500 deductible or less
• $6,850 out-of-pocket maximum or less
• Unlimited medical maximum
• Meets or exceeds Affordable Care Act requirements
• Unlimited medical evacuation and repatriation of
remains
12
For questions regarding insurance waivers, please
contact Luanda Warren at Ascension Benefits &
Insurance Solutions at (800) 955-1991, ext. 7464.
Ascension Benefits &
Insurance Solutions
UNMC Waiver of
Deductible
Ascension Benefits & Insurance Solutions is the student
insurance plan and waiver administrator for the University
of Nebraska System. Ascension is a full-service broker
and plan administrator, specializing in student health
insurance for colleges and universities across the United
States. Ascension is an independent company and not
affiliated with Blue Cross and Blue Shield of Nebraska. To
learn more, visit www.ascensionins.com.
You are encouraged to use the services of the University
Student Health Clinic whenever possible. The $500
deductible will be waived by Blue Cross and Blue Shield
of Nebraska for covered treatment received at the UNMC
Student Health Clinic and subsequent APPROVED
REFERRALS to UNMC Physicians while you are being
treated at The Nebraska Medical Center only (no other
University site) on an inpatient or outpatient basis.
Note: All terms above must be followed before the
deductible is waived.
The University of Nebraska student insurance
plan also offers travel assistance and accidental
death and dismemberment (AD&D) coverage at
no additional charge to you when you enroll in
StudentBlue. Travel assistance and AD&D coverage
is separate from StudentBlue. To learn more, visit
nebraskablue.com/studentblue.
13
access
50
IN ALL
S TAT E S
Student Health Clinics and BCBSNE's Provider Network
Statewide, Nationwide, and Around the World
All students are encouraged to obtain
medical services at a University of
Nebraska System student health
clinic. Medical services covered at
UNK, UNL, UNMC, and UNO student
health clinics are paid at 100%. These
services include most laboratory,
physical therapy, radiology, specialty,
counseling, and psychological
services, as well as annual exam
expenses.
If you choose to obtain medical
services at another facility, consider
using a provider in BCBSNE's
NEtwork BLUE network. In doing so
you will pay less out of pocket than if
you use an out-of-network provider.
Read on for more information.
14
A health plan is only as good as its provider network. With Blue Cross and
Blue Shield of Nebraska (BCBSNE) coverage, you can have peace of mind
knowing that you have access to a large network of hospitals, doctors, and
other health care providers. Our NEtwork BLUE network is made up of
91% of Nebraska's doctors and 100% of the state's hospital and medical
facilities. That makes obtaining in-network care easy and convenient.
In-network providers have agreed to accept our benefit payment for
covered services as payment in full, except for any deductible, copays,
coinsurance amounts and charges for noncovered services, which are your
responsibility. This means that in-network providers, under the terms of
their contract with us, can’t bill you for amounts over our benefit allowance. Please be aware that out-of-network providers can bill patients for
amounts in excess of the amount payable under the contract.
In-network providers also file claims for Blue Cross and Blue Shield of
Nebraska members, meaning you have less paperwork to worry about.
And as an additional time-saving convenience, we send our benefit
payment directly to in-network providers.
How to Locate NEtwork BLUE
Providers in Nebraska
How to Locate BlueCard Program Providers
Nationwide
Search our online provider directory: Go to nebraskablue.
com and select the “Find a Doctor” tab to access our online
directory of NEtwork BLUE providers.
Search our online provider directory: Go to nebraskablue.
com and select the “Find a Doctor” tab to access our online
directory of national providers.
Call: If you are a BCBSNE member, please call the phone
number on the back of your BCBSNE member ID card.
Call: 1-800-810-BLUE (2583)
The BlueCard® Program
If you or any of your covered family members live or travel
outside of Nebraska, you can obtain covered services at the
in-network level through the BlueCard Program.
The BlueCard Program makes obtaining in-network care
easy. All you have to do is use hospitals and doctors in
the local Blue Cross and Blue Shield Plan’s BlueCard PPO
network. When you do, you will also enjoy the discount and
claim filing arrangements Blue Cross and Blue Shield Plans
across the country have negotiated with BlueCard network
hospitals and doctors in their area.
Traveling Outside the U.S.
BlueCard Worldwide® enables Blue Cross and Blue Shield
Plan members traveling or living abroad to obtain medical
assistance and inpatient, outpatient and professional
services from a network of health care providers worldwide. BlueCard Worldwide currently includes hospitals and
doctors in nearly 200 countries.
BlueCard Worldwide gives you access to available services
24 hours a day, seven days a week, at no additional cost.
These include locating inpatient, outpatient and professional
services, medical assessments and translators, and making
doctor appointments and hospitalization arrangements.
15
How Using In-network Dentists Benefits You
Our dental network in Nebraska is part of a larger provider
network of multiple Blue Cross and Blue Shield Plans that,
when combined, offers one of the largest national PPO
dental networks. It provides you and your covered family
members with lower out-of-pocket costs and broad access
to participating dentists.
If you or your covered family members live or travel outside
of Nebraska, you will be able to obtain covered services at
the in-network level of benefits through the combined PPO
dental network.
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How to Locate In-network
Dentists in Nebraska
By phone:
1-877-721-2583
On the web:
nebraskablue.com/find-a-doctor
Online Tools and Resources
Learn what myblue has to offer:
BCBSNE's Online Member Services
It only takes a couple of minutes for BCBSNE members to gain
access to a wealth of online tools that give you more control
over your health plan and personal wellness. After signing up at
mynebraskablue.com, you’ll instantly access details about your
insurance plan and be able to track your spending. It’s called
my blue, and it’s just for you!
Log in to myblue and find tools to help answer
important health care questions. All of these
tools are under the Tools & Resources tab:
Know Before You Go
In the What’s it Cost section, you can estimate
medical costs before you receive care. Here
you can find cost information for many common
health care services, and compare costs of
doctors and hospitals.
Review Your Doctor
In the Find a Doctor or Hospital section, you
can write a review of your health care experience and read reviews written by others.
MyPrime®
Blue Cross and Blue Shield of Nebraska
contracts with Prime Therapeutics® to provide
group pharmacy benefits. You may view
information about your pharmacy benefits by
going to My Pharmacy. You will be directed
to MyPrime. This website is loaded with
interactive tools to help you manage your
prescription drugs.
With MyPrime, you can find:
• your prescription benefits
At my blue you can make sense of your medical bills and health
care spending – all in one place.
> Track your health care spending
> Access your mobile ID card or order printed cards
> View a summary of your claims activity
> Find a doctor close to work or home
• your drug claim history
• prescription drug list (also known as
a formulary)
• a pharmacy locator
• a drug cost calculator
• a comparison of brand name and
generic drug costs
> Get in touch with us
To learn more, visit mynebraskablue.com. If you are a BCBSNE
member, log in (or sign up if you haven’t already registered). If you
are not yet a BCBSNE member, you may visit the site as a guest.
Select “Guest” above the green box.
Prime Therapeutics LLC is an independent company
providing pharmacy benefit management services.
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Prescription Drug Benefits
Blue Cross and Blue Shield of Nebraska
is committed to providing you with valuable information you can use to manage
your prescription drug purchases.
Your prescription drug benefits are
based on Blue Cross and Blue Shield
of Nebraska’s drug formulary or list
of generic and brand name drugs.
The copays/coinsurance you pay for a
prescription drug depend on whether
or not the drug is included in the
formulary, and if the drug is generic or
brand name:
• Lowest copay/coinsurance =
generic drugs
• Middle copay/coinsurance =
formulary brand name drugs
• Highest copay/coinsurance =
nonformulary brand name drugs
Whenever appropriate, generic drugs
will be used to fill your prescriptions.
If you prefer a brand name drug when
a generic equivalent is available, you
will be responsible for the difference in
cost, plus the applicable copay/coinsurance amount.
You do not have to use formulary
medications, but if you do, you will
pay less out of pocket. To review
the BCBSNE formulary online, visit
nebraskablue.com/druglist.
Retail Pharmacies
BCBSNE’s retail pharmacy network is
Rx Nebraska. This network features
more than 66,000 in-network retail
pharmacies nationwide. You may have
your prescriptions filled at any pharmacy
you wish. However, you will pay less
out-of-pocket on prescriptions when
you use an Rx Nebraska in-network
pharmacy.
To locate in-network Rx Nebraska pharmacies nationwide, visit
www.nebraskablue.com/myprime. Or
call toll-free 1-877-800-0746.
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PrimeMail® Mail Service Pharmacy
Specialty Drug Benefits
Prime Therapeutics’ mail service
pharmacy offers mail delivery of your
maintenance or long-term medications with the highest standards of
quality, safety and service. Ordering
maintenance or long-term medications
through PrimeMail can offer you many
advantages, including:
Specialty medications are drugs used
to treat serious or chronic medical
conditions such as multiple sclerosis,
hemophilia, hepatitis and rheumatoid
arthritis. The Blue Cross and Blue Shield
of Nebraska specialty drug program
provides a convenient, cost-effective
way for you to order specialty medications for delivery directly to your home
or physician’s office.
• Cost savings
• Convenient home delivery and
ordering options
• Medications dispensed by registered
pharmacists
• Outstanding customer service
If you use PrimeMail, you may order up
to a 90-day supply of your maintenance
medication at one time (if allowed by
your prescription).
To learn more about PrimeMail, go to
www.nebraskablue.com/mailorder.
PrimeMail is a registered trademark
of Prime Therapeutics, LLC. Prime
Therapeutics is an independent
company providing pharmacy benefit
management services.
BCBSNE members are required to
purchase specialty drugs at a designated specialty pharmacy.
For more information, visit
www.nebraskablue.com/specialtydrugs.
EveryMove is on a mission to change lives through
physical activity by bringing together healthy goals,
tracked activity data, and fitness-minded friends.
Connect your movement through popular fitness
apps and devices, or enter your movements on the
EveryMove website.
Visit www.everymove.org to learn more.
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.
Nebraska’s comprehensive source for
wellness news and information
Pursue fitness goals with family, friends or
coworkers and find fitness inspiration.
EveryMove is an independent company with whom Blue Cross and Blue
Shield of Nebraska has contracted to provide wellness programs and services.
Every­Move is solely responsible for its programs and services and does not
provide Blue Cross and Blue Shield of Nebraska programs or services.
Maternity Management Program
If you’re expecting you want to know all
you can about healthy pregnancies so your
newborn will get the best start in life.
Blue Cross and Blue Shield of Nebraska,
in cooperation with your physician, wants
to help you learn about this exciting time
and offers you assistance in maintaining a
healthy pregnancy. Our program can provide
you information to help ensure a healthy
pregnancy or work with your physician to
coordinate specialized care. Best of all, this
program is offered at no cost to you.
To learn more, visit
nebraskablue.com/maternitycare.
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A New and Innovative Way to
Access Health Care 24/7/365!
Blue Cross and Blue Shield of Nebraska
(BCBSNE) believes in the importance
of providing options to help you access
affordable and immediate health care.
That is why we are delighted to offer
telehealth to our members.
Telehealth Services
How does it work?
Telehealth is an innovative patient
consultation service that lets you connect
with a U.S. board certified, licensed and
credentialed doctor quickly and easily using
your computer, tablet or phone. It’s easy to
use, affordable, private and secure.
Rather than having to schedule a doctor’s
appointment and travel to and from the
doctor’s office, telehealth lets you interact
with a doctor at your convenience for
common conditions, such as:
• sinus infection
• cold
• flu
• fever
• rash
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• abdominal pain
• pinkeye
• ear infection
• migraine
• sore throat
Board-Certified Doctors
Who provides telehealth services?
Blue Cross and Blue Shield of Nebraska provides
telehealth services through American Well®, also
known as Amwell, the industry’s leader in telehealth
solutions. With Amwell, you can register for free, and
the cost per visit is less than the cost of an in-person
doctor office visit.
Amwell offers:
• A choice of trusted, U.S. board-certified doctors
• Access to a licensed physician via computer, tablet
or phone
• Consultation and diagnosis for common conditions,
including e-prescriptions to your pharmacy of choice
(when appropriate and where allowed*)
Convenient and Easy
You never know when you may
need a doctor.
Telehealth can be used any time, day or night. It’s perfect
when your doctor’s office is closed, you’re too sick or busy
to see someone in person, or even when you’re traveling.
Register Now
There are three easy ways to register:
1. Download the Amwell app on your mobile device
from the Apple App Store or Google Play
2. Visit nebraskablue.com/telehealth
3. Call toll-free 844-SEE-DOCS (844-733-3627)
When prompted, enter Service Key BCBSNE to get the
Blue Cross and Blue Shield of Nebraska member rate.
*Telehealth is available in most states, but some states do not allow telehealth consults or telehealth prescriptions. For more information, visit:
info.americanwell.com/where-can-i-see-a-doctor-online. American Well is an independent
company that provides telehealth services for Blue Cross and Blue Shield of Nebraska.
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Telehealth Quick Start Guide
MOBILE REGISTRATION
1.
Search the App Store
or Google Play for
“Amwell.”
4.
When you are ready to
have a visit, choose a
provider and enter the
necessary information
(symptoms, pharmacy of
choice, optional medical
history, current medications and vitals). Next,
enter your insurance
information and payment
information.
5.
Begin your visit!
Download the
Amwell app.
22
2.
Click “Sign Up for
Amwell” at the
bottom of the screen.
Fill out your personal
information, your email,
create a password,
and enter BCBSNE for
your Service Key under
“optional information”
to get the Blue Cross
and Blue Shield of
Nebraska member rate.
3.
Select Blue Cross Blue
Shield of Nebraska
from the insurance drop
down and enter your
member ID number
shown on the front of
your Blue Cross and
Blue Shield of Nebraska
member ID card.
Telehealth Quick Start Guide
WEB REGISTRATION
sign up for Amwell, visit:
1. Towww.nebraskablue.com/telehealth
5.
hen you are ready to have a visit, choose a provider
W
and enter the necessary information (symptoms,
pharmacy of choice, optional medical history, current
medications and vitals). Next, enter your insurance
information and payment information.
6.
ou will connect with Enhanced Video and see the
Y
provider in high definition.
ill out your name, email, create a password and
2. Fclick
the green “Sign Up” button.
3.
4.
ill out your location,
F
birthday, and gender
and click “Continue.”
elect that you have health
S
insurance. Pick Blue Cross
Blue Shield of Nebraska
from the insurance drop
down and enter your member ID number from your
Blue Cross and Blue Shield
of Nebraska member ID
card. Then, enter BCBSNE
in the Service Key field to
get the Blue Cross and
Blue Shield of Nebraska
member rate. Click “Finish.”
23
HELPING YOU
FOCUS ON
YOUR FUTURE
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Identity Protection Services
from AllClear ID
Blue Cross and Blue Shield of Nebraska
(BCBSNE) has teamed with AllClear ID to
offer all eligible BCBSNE members access to
AllClear Secure identity repair and the option
to enroll in AllClear Pro credit monitoring.
You and your eligible family members will automatically
receive AllClear Secure identity repair at no cost to
you.This service protects you everywhere, including
the internet, for as long as you are enrolled in a Blue
Cross and Blue Shield of Nebraska health plan.
If you become a victim of identity theft, AllClear ID will
help do the work to recover your financial losses and
restore your credit report—at no cost to you, ever.
If you have questions about protecting your identity,
or if you suspect your identity has been stolen:
1. Call the award-winning AllClear ID customer
support team at 855-229-0079.
2.Provide your redemption code NebraskaBlue2016
as proof of eligibility.
3.Let AllClear ID help recover your losses and
restore your credit.
How Identity Repair Works
If you experience identity theft, a dedicated
investigator from AllClear ID will act as your guide
and advocate from start to finish by initiating the
dispute process, and ensuring that your identity
returns to its pre-fraud state.
Enhance Your Protection with Credit
Monitoring
With AllClear Pro credit monitoring service, you can
have additional layers of protection that specifically
moni­tor new credit accounts opened in your name.
If this happens, AllClear ID sends alerts to you so
you stay informed of your credit activity.
You and your eligible family members may enroll
in AllClear Pro – at no cost to you. (While AllClear
Secure is automatic protection, you must enroll in
credit monitoring because you will need to provide
AllClear ID with personal information such as your
Social Security number.)
You may enroll in AllClear Pro credit monitoring
anytime.
To Enroll
Call toll-free 855-229-0079
Or visit enroll.allclearid.com
(enter the redemption code NebraskaBlue2016)
AllClear ID provides identity protection services for eligible Blue Cross and Blue Shield of Nebraska
health plan members. AllClear ID is an independent company and is responsible for its services.
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Inpatient Certification
Special Enrollment Rights
Important: When possible, certification as described
below should be completed prior to an inpatient admission.
Benefits may be denied if the admission does not meet the
criteria for inpatient care. Benefits for services that are not
medically necessary will be denied.
If you are declining enrollment for yourself or your
dependents (including your spouse) because of other health
insurance or group health plan coverage, you may be able
to enroll yourself and your dependents in this plan if you
or your dependents lose eligibility for that other coverage
(or if the employer stops contributing toward your or your
dependents’ other coverage). However, you must request
enrollment within 31 days after your or your dependent’s
other coverage ends (or after the employer stops contributing toward the other coverage).
Blue Cross and Blue Shield of Nebraska must be notified
of all inpatient hospital or facility admissions. This enables
us to determine if services are appropriate under the terms
of the health plan, and coordinate discharge planning and
case management services with the patient’s providers. If
the patient is admitted to an in-network hospital/facility in
Nebraska, notification will be provided by the hospital/facility.
If the patient is hospitalized in an out-of-network hospital/
facility in Nebraska or is admitted to an inpatient facility
in another state, Blue Cross and Blue Shield of Nebraska
must be notified by you, the physician or the facility.
Benefits must be certified for the following inpatient care:
• Inpatient hospital admissions (except maternity admission)
• Inpatient admissions for mental illness or substance
abuse
• Physical rehabilitation
• Long term acute care
• Skilled nursing facility care
• Hospice care
For certification of benefits for an inpatient admission, call:
(402) 390-1870 or 1-800-247-1103.
In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be
able to enroll yourself and your dependents. However, you
must request enrollment within 31 days after the marriage,
birth, adoption or placement for adoption.
If you are declining coverage for yourself or your dependents because of coverage under Medicaid or a State
Child Health Insurance Program (SCHIP), you may be able
to enroll yourself or your dependents in this plan if that
coverage terminates due to a loss of eligibility. You must
request enrollment in the plan no later than 60 days after
the termination of coverage.
Additionally, if you decline coverage and you or your
dependents become eligible for premium assistance for
this group health plan under Medicaid or SCHIP, you or your
dependents may be able to enroll in the plan at that time.
You must request enrollment no later than 60 days after
the date you are determined to be eligible for the premium
assistance.
To request special enrollment or obtain more information,
contact the Blue Cross and Blue Shield of Nebraska’s
Member Services Department.
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Noncovered Medical Services
Noncovered Dental Services
This brochure contains only a partial listing of the limitations
and exclusions that apply to this health care coverage.
A more complete list may be found in the master group
contract or by referring to the certificate of coverage and
schedule of benefits.
The following is only a partial listing of the exclusions and
limitations that apply to the University of Nebraska student
dental coverage. A complete list is in the master contract.
No benefits are available for the following unless otherwise
specified in the policy:
• Services not identified as covered under Coverages A and
B in the contract
• Audiological exams (except newborn); hearing aids and
their fitting
• Abortions (except to save the life of the mother)
No benefits are available for the following unless otherwise
specified in the policy:
• Dental services related to congenital malformations or
primarily for cosmetic purposes.
• Blood, blood plasma or services by or for blood donors
• Services for orthodontic dentistry and treatment of the
temporomandibular jaw joint
• Artificial insemination; invitro fertilization; fertility treatment, and related testing
• Supplies, education or training for dietary or nutrition
counseling, personal oral hygiene or dental plaque control.
• Massage therapy
• Services received before the effective date of coverage or
after termination of coverage
• Treatment for weight reduction/obesity, including surgical
procedures
• Nutrition care, supplies, supplements or other nutritional
substances, including Neocate, Vivonex, and other overthe-counter nutritional substances
• 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 determined to be not medically necessary,
investigative, or obsolete
• Charges in excess of our contracted amount
• Services covered under Workers’ Compensation or
Employers’ Liability Law
• Services provided by a person who is not a dentist, or by a
dental hygienist not under the dentist’s direct supervision
• Charges made separately for services, supplies
and materials considered to be included within
the total charge payable
• Services provided before the coverage effective date or
after termination
• Services for illness or injury related to military services
• 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
• Charges in excess of our contracted amount
• Charges made separately for services, supplies and
materials we consider to be included within the total
charge payable
• Services provided to University student athletes who are
covered under a plan or contract providing coverage only
for student athletes, unless otherwise subject to coordination of benefits or an alternative agreement with us
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This brochure provides you with an
overview of the Blue Cross and Blue
Shield of Nebraska health and dental
coverage offered to University of
Nebraska System students. This is not
a contract. It is intended as a general
overview only. It does not contain all
the details of this coverage. For more
complete information about your plan,
including benefits, exclusions and
contract limitations, please refer to the
certificate of coverage or the master
group contract. In the event there are
discrepancies between this document
and the contract, the terms and
conditions of the contract will govern.
Blue Cross and Blue Shield of Nebraska is an independent
licensee of the Blue Cross and Blue Shield Association.
92-149 (04-22-16)