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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 2 2 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 3 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 4 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 5 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 6 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. 7 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 8 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. 11 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. 16 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. 17 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. 18 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. 19 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 20 • 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. 21 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 24 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. 25 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. 26 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 27 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)