Benefits

Health Insurance

Provider

Blue Cross and Blue Shield of Nebraska

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Group #101498
NEtwork BLUE Network
1-888-592-8961

Pharmacy Network

Network C

Drug List

PDL 10 (Formerly “BCBSNE Standard Formulary“)

WoodmenLife Associates at the Gym

Compare HRA and HSA

D/C = Deductible/Coinsurance

Associate Plus means Associate + Child(ren), Associate + Spouse or Associate + Family

Full Glossary of Terms
HSA
Benefit Summary In-Network Out-of-Network
Deductible/
Coinsurance
Aggregate
Associate $1,500 $3,000
Associate Plus $3,000 $6,000
Coinsurance 25% 40%
Out-of-Pocket Maximum
includes Deductible, Coinsurance and Copays
Associate $3,000 $6,000
Associate Plus $6,000 $12,000
WoodmenLife HSA or HRA Contributions
For associates not enrolled for the entire year, WoodmenLife’s contribution will be prorated based on the coverage start date.
Associate $500
Associate Plus $1,000
Office Visit
Primary Care D/C D/C
Specialist D/C D/C
Other Office Visit Services D/C D/C
Preventive Care 100% D/C
Virtual Doctor D/C D/C
Urgent and Emergency Care
Physician D/C D/C
Other Urgent Care Services D/C D/C
Emergency Care D/C Same as In-Network
Prescription Drug Retail 30-day supply
Generic D/C In-Network + 25%
Formulary D/C In-Network + 25%
Non-Formulary D/C In-Network + 25%
Specialty D/C Not covered
Prescription Drug Retail 90-day supply
Generic D/C Not covered
Formulary D/C Not covered
Non-Formulary D/C Not covered
HRA
Benefit Summary In-Network Out-of-Network
Deductible/
Coinsurance
Aggregate
Associate $2,000 $4,000
Associate Plus $4,000 $8,000
Coinsurance 30% 50%
Out-of-Pocket Maximum
includes Deductible, Coinsurance and Copays
Associate $4,500 $9,000
Associate Plus $9,000 $18,000
WoodmenLife HSA or HRA Contributions
For associates not enrolled for the entire year, WoodmenLife’s contribution will be prorated based on the coverage start date.
Associate $1,000
Associate Plus $2,000
Office Visit
Primary Care $30 Copay D/C
Specialist D/C D/C
Other Office Visit Services Included in Copay D/C
Preventive Care 100% D/C
Virtual Doctor $15 Fee D/C
Urgent and Emergency Care
Physician $55 Copay D/C
Other Urgent Care Services Included in Copay D/C
Emergency Care $175 Copay + D/C Same as In-Network
Prescription Drug Retail 30-day supply
Generic $15 Copay In-Network + 25%
Formulary 30%, $37.50 min to $150 max In-Network + 25%
Non-Formulary 30%, $62.50 min to $250 max In-Network + 25%
Specialty 30%, $75 min to $300 max Not covered
Prescription Drug Retail 90-day supply
Generic $37.50 Copay Not covered
Formulary 30%, $93.75 min to $375 max Not covered
Non-Formulary 30%, $156.25 min to $625 max Not covered
HSA HRA
Benefit Summary In- Network Out-of-Network In- Network Out-of-Network
Deductible/Coinsurance Aggregate Aggregate
Associate $1,500 $3,000 $2,000 $4,000
Associate Plus $3,000 $6,000 $4,000 $8,000
Coinsurance 25% 40% 30% 50%
Out-of-Pocket Maximum
includes Deductible, Coinsurance and Copays
Associate $3,000 $6,000 $4,500 $9,000
Associate Plus $6,000 $12,000 $9,000 $18,000
WoodmenLife HSA or HRA Contributions
For associates not enrolled for the entire year, WoodmenLife’s contribution will be prorated based on the coverage start date.
Associate $500 $1,000
Associate Plus $1,000 $2,000
Office Visit
Primary Care D/C D/C $30 Copay D/C
Specialist D/C D/C D/C D/C
Other Office Visit Services D/C D/C Included in Copay D/C
Preventive Care 100% D/C 100% D/C
Virtual Doctor D/C D/C $15 Fee D/C
Urgent and Emergency Care
Physician D/C D/C $55 Copay D/C
Other Urgent Care Services D/C D/C Included in Copay D/C
Emergency Care D/C Same as In-Network $175 Copay + D/C Same as In-Network
Prescription Drug Retail 30-day supply
Generic D/C In-Network + 25% $15 Copay In-Network + 25%
Formulary D/C In-Network + 25% 30%, $37.50 min to $150 max In-Network + 25%
Non-Formulary D/C In-Network + 25% 30%, $62.50 min to $250 max In-Network + 25%
Specialty D/C Not covered 30%, $75 min to $300 max Not covered
Prescription Drug Retail 90-day supply
Generic D/C Not covered $37.50 Copay Not covered
Formulary D/C Not covered 30%, $93.75 min to $375 max Not covered
Non-Formulary D/C Not covered 30%, $156.25 min to $625 max Not covered

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HRA Details

HSA Details

Pre-Tax Premiums

Total health insurance cost, paid by you and WoodmenLife, is based on actual claims over the prior two years, projected claims, administrative expenses for the upcoming year, the plan and level of coverage you select, and your salary/earnings as of Sept. 30.

Benefits of an HSA

To help understand the benefits of a Health Savings Account, click here.

Tax Reporting

Click here for tax information related to health insurance.