Blue Cross Blue Shield Nebraska MA Access (PPO)
Blue Cross and Blue Shield of Nebraska
Medicare Advantage Plan (with drug coverage)
Plan ID: H8181-001-0 | Stanton County, NE | 2021
Rating Not Available
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Medicare Plan Overall Rating
Blue Cross Blue Shield Nebraska MA Access Drug Coverage and Costs in Stanton County, NE
| Blue Cross Blue Shield Nebraska MA Access | |
|---|---|
| Drug Coverage |  |
| Plan Type | PPO |
| Total Monthly Premium | $26.00 |
| Health Plan Premium | $0.00 |
| Drug Plan Premium | $26.00 |
| Standard Part B Premium | $148.50 |
| Max You Pay for Health Services (in-network) | $4,500.00 |
| Part D Deductible | $100.00 |
| Select Plan |
Doctors, Specialists, Tests, Labs, Imaging
| Blue Cross Blue Shield Nebraska MA Access | |
|---|---|
| Primary Doctor Visit |
$5 copay per visit (in-network) $15 copay per visit (out-of-network) |
| Specialist Visit |
$30 copay per visit (in-network) $40 copay per visit (out-of-network) |
| Diagnostic Tests & Procedures |
$20-350 copay (in-network) $20-350 copay (out-of-network) |
| Lab Services |
$0 copay (in-network) $20 copay (out-of-network) |
| Diagnostic Radiology Services (like MRI) |
$100-350 copay (in-network) $20-350 copay (out-of-network) |
| Outpatient X-rays |
$15-350 copay (in-network) $20-350 copay (out-of-network) |
Hospitals, Skilled Nursing, Urgent Care
| Blue Cross Blue Shield Nebraska MA Access | |
|---|---|
| Emergency Care | $90 copay per visit (always covered) |
| Urgent Care | $65 copay per visit (always covered) |
| Ambulance (Ground) |
$325 copay (in-network) $325 copay (out-of-network) |
| Inpatient Hospital Coverage |
$420 per day for days 1 through 4 $0 per day for days 5 through 90 (in-network) $420 per day for days 1 through 4 $0 per day for days 5 through 90 (out-of-network) |
| Outpatient Hospital Coverage |
$350 copay per visit (in-network) $350 copay per visit (out-of-network) |
| Skilled Nursing Facility Stays |
$0 per day for days 1 through 20 $179 per day for days 21 through 46 $0 per day for days 47 through 100 (in-network) $0 per day for days 1 through 20 $179 per day for days 21 through 59 $0 per day for days 60 through 100 (out-of-network) |
| Preventive Services |
$0 copay (in-network) $0 copay (out-of-network) |
Hearing and Vision
| Blue Cross Blue Shield Nebraska MA Access | |
|---|---|
| Hearing Exam |
$5-30 copay (in-network) $0-65 copay (out-of-network) |
| Hearing Fitting / Evaluation |
$0 copay (in-network) $0 copay (out-of-network) |
| Hearing Aides - All Types |
$0 copay (in-network) $0 copay (out-of-network) |
| Routine Eye Exam |
$0 copay (in-network) 50% coinsurance (out-of-network) |
| Contact Lenses |
$0 copay (in-network) 50% coinsurance (out-of-network) |
| Eyeglasses (Frames & Lenses) | Not covered |
| Eyeglass Frames (only) |
$0 copay (in-network) 50% coinsurance (out-of-network) |
| Eyeglass Lenses (only) |
$0 copay (in-network) 50% coinsurance (out-of-network) |
| Upgrades (vision) | Not covered |
Physical, Occupational, Speech Therapy and Mental Health
| Blue Cross Blue Shield Nebraska MA Access | |
|---|---|
| Occupational Therapy Visit |
$40 copay (in-network) $40 copay (out-of-network) |
| Physical Therapy Visit |
$40 copay (in-network) $40 copay (out-of-network) |
| Speech Pathology Visit |
$40 copay (in-network) $40 copay (out-of-network) |
| Outpatient Group Therapy with a Psychiatrist |
$40 copay (in-network) $40 copay (out-of-network) |
| Outpatient Individual Therapy with a Psychiatrist |
$40 copay (in-network) $40 copay (out-of-network) |
| Outpatient Group Therapy Visit |
$40 copay (in-network) $40 copay (out-of-network) |
| Outpatient Individual Therapy Visit |
$40 copay (in-network) $40 copay (out-of-network) |
Dental Coverage
| Blue Cross Blue Shield Nebraska MA Access | |
|---|---|
| Oral Exam |
$0 copay (in-network) $0 copay (out-of-network) |
| Oral Cleaning |
$0 copay (in-network) $0 copay (out-of-network) |
| Flouride Treatment | Not covered |
| Dental X-rays |
$0 copay (in-network) $0 copay (out-of-network) |
| Non-routine Services | Not covered |
| Diagnostic Services |
$0 copay (in-network) $0 copay (out-of-network) |
| Restorative Services |
$0 copay (in-network) $0 copay (out-of-network) |
| Endodontics |
$0 copay (in-network) $0 copay (out-of-network) |
| Periodontics |
$0 copay (in-network) $0 copay (out-of-network) |
| Extractions |
$0 copay (in-network) $0 copay (out-of-network) |
| Prosthodontics, Other Oral / Maxillofacial Surgery, Other Services |
$0 copay (in-network) $0 copay (out-of-network) |
Medical Equipment, Dialysis, Diabetes
| Blue Cross Blue Shield Nebraska MA Access | |
|---|---|
| Durable medical equipment (like wheelchairs & oxygen) |
20% coinsurance per item (in-network) 20% coinsurance per item (out-of-network) |
| Prosthetics (like braces, artificial limbs) |
20% coinsurance per item (in-network) 20% coinsurance per item (out-of-network) |
| Diabetes Supplies |
0-20% coinsurance per item (in-network) 0-20% coinsurance per item (out-of-network) |
Drug Coverage and Costs (Initial Coverage Phase)
| Blue Cross Blue Shield Nebraska MA Access | |
|---|---|
| Preferred Retail Pharmacy (1 month supply) | |
| Preferred Generic | $0.00 copay |
| Generic | $8.00 copay |
| Preferred Brand | $37.00 copay |
| Non-Preferred Brand | $100.00 copay |
| Specialty Tier | 31% |
| Standard Retail Pharmacy (1 month supply) | |
| Preferred Generic | $12.00 copay |
| Generic | $18.00 copay |
| Preferred Brand | $47.00 copay |
| Non-Preferred Brand | $100.00 copay |
| Specialty Tier | 31% |
| Standard Mail Order Pharmacy (3 month supply) | |
| Preferred Generic | $0.00 copay |
| Generic | $0.00 copay |
| Preferred Brand | $111.00 copay |
| Non-Preferred Brand | $300.00 copay |
Important Plan Information
Plan limits may apply for the above services - There may be limits on how much the plan will provide.
Advanced Plan Approval May be Required for the above services - A process through which the physician or other health care provider is required to obtain advance approval from the plan that payment will be made for a service or item furnished to an enrollee. Unless specified otherwise with respect to a particular item or service, the enrollee is not responsible for obtaining (prior) authorization.
Physician Referral May be Required - A process through which the enrollee’s primary care physician or other network physician (depending on the plan policy) permits or instructs the enrollee to obtain an item or service from another physician or other provider type.
FOR INFORMATIONAL PURPOSES ONLY
The plans listed on this page are for informational purposes only. SeniorFax has no plan affiliations and does not endorse any plans displayed. The information provided is based on publicly available data from the Centers for Medicare & Medicaid Services (CMS). Current data is accessible on medicare.gov. Not connected with or endorsed by the U.S. Government or the federal Medicare program. Actual plan costs and coverage can vary. Always consult a licensed insurance agent before purchasing insurance products.
Medicare Star Rating Performance
| SAPPHIRE EDGE, INC. Blue Cross and Blue Shield of Nebraska |
Medicare Rating Not Available | |||
| Summary Rating of Health Plan Quality | Not Available | |||
| Staying Healthy: Screenings, Tests, & Vaccines | Not Available | |||
| Breast cancer screening | Not Available | |||
| Colorectal cancer screening | Not Available | |||
| Yearly flu vaccine | Not Available | |||
| Improving or maintaining physical health | Not Available | |||
| Improving or maintaining mental health | Not Available | |||
| Monitoring physical activity | Not Available | |||
| Checking to see if members are at a healthy weight | Not Available | |||
| Managing Chronic (Long-term) Conditions | Not Available | |||
| Members whose plan did an assessment of their health needs and risks | Not Available | |||
| Yearly review of all medications and supplements being taken | Not Available | |||
| Yearly assessment of how well plan members are able to do activities of daily living | Not Available | |||
| Yearly pain screening or pain management plan | Not Available | |||
| Osteoporosis management | Not Available | |||
| Eye exam to check for damage from diabetes | Not Available | |||
| Kidney function testing for members with diabetes | Not Available | |||
| Plan members with diabetes whose blood sugar is under control | Not Available | |||
| Rheumatoid arthritis management | Not Available | |||
| Reducing the risk of falling | Not Available | |||
| Improving bladder control | Not Available | |||
| The plan makes sure member medication records are up-to-date after hospital discharge | Not Available | |||
| The plan makes sure members with heart disease get the most effective drugs to treat high cholesterol | Not Available | |||
| Member Experience with Health Plan | Not Available | |||
| Ease of getting needed care and seeing specialists | Not Available | |||
| Getting appointments and care quickly | Not Available | |||
| Health plan provides information or help when members need it | Not Available | |||
| Member's rating of health care quality | Not Available | |||
| Member's rating of health plan | Not Available | |||
| Coordination of members' health care services | Not Available | |||
| Member Complaints & Changes in the Health Plan's Performance | Not Available | |||
| Complaints about the health plan (more stars are better because it means fewer complaints) | Not Available | |||
| Members choosing to leave the plan (more stars are better because it means fewer members choose to leave the plan) | Not Available | |||
| Improvement (if any) in the health plan's performance | Not Available | |||
| Health Plan Customer Service | Not Available | |||
| Health plan makes timely decisions about appeals | Not Available | |||
| Fairness of the health plan's appeal decisions, based on an independent reviewer | Not Available | |||
| Availability of TTY services and foreign language interpretation when prospective members call the health plan |
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| Drug Plan (Part D) Star Rating | Not Available | |||
| Drug Plan Customer Service | Not Available | |||
| Availability of TTY services and foreign language interpretation when prospective members call the drug plan |
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| Drug plan fails to make timely decisions about appeals (more stars are better because it means fewer delays) | Not Available | |||
| Fairness of drug plan's appeal decisions, based on an independent reviewer | Not Available | |||
| Member Complaints & Changes in the Drug Plan's Performance | Not Available | |||
| Complaints about the drug plan (more stars are better because it means fewer complaints) | Not Available | |||
| Members choosing to leave the plan (more stars are better because it means fewer members choose to leave the plan) | Not Available | |||
| Improvement (if any) in the drug plan's performance | Not Available | |||
| Member Experience with the Drug Plan | Not Available | |||
| Members' rating of drug plan | Not Available | |||
| Ease of getting prescriptions filled when using the plan | Not Available | |||
| Drug Safety & Accuracy of Drug Pricing | Not Available | |||
| Plan provides accurate drug pricing information for Medicare's website | Not Available | |||
| Taking diabetes medication as directed | Not Available | |||
| Taking blood pressure medication as directed | Not Available | |||
| Taking cholesterol medication as directed | Not Available | |||
| Members who had a pharmacist (or other health professional) help them understand and manage their medications | Not Available | |||
| The plan makes sure members with diabetes take the most effective drugs to treat high cholesterol | Not Available | |||
Last Updated: September 19, 2021
