Two women in retirement walking outside for exercise

BENEFITS

Health Insurance

Provider

Group #101498
NEtwork BLUE Network
1-888-592-8961
PDL 10 (Formerly “BCBSNE Standard Formulary“)

WoodmenLife’s health care coverage gives you the flexibility to choose the best plan option for you and your eligible dependents. Each plan has an in-network or out-of-network level of participation. If you retire prior to Dec. 31, and were enrolled in the Select HRA Plan while active, you will remain enrolled in the Select HRA Plan until the end of the calendar year you retire or when you become Medicare eligible.

Eligible dependents include:

  • Legally married spouse, according to federal law

  • Married or unmarried children up to age 26, including stepchildren, legally adopted grandchildren, and children under court-appointed guardianship

  • Disabled children

  • Dependent maternity is not covered

PREMIUM CHART - SELECT HRA OR HSA

Select HRA or Select HSA Plan1 Monthly Premiums

Retiree Years of Service

Retiree (Non-Medicare-Eligible)

Spouse (Non-Medicare-Eligible)

Child(ren)

30 years and over

$530.90

$1,280.88

$602.69

20 to 29 years

$1,015.83

$1,532.16

$602.69

5 to 19 years

$1,532.16

$602.69

Please remember the total monthly retiree premium you pay is determined by adding the retiree, spouse and children premium amounts together, which may include Medicare premiums.

COMPARE HRA AND HSA

D/C  = Deductible/Coinsurance

HSA

HRA

Benefit Summary

Deductible/Coinsurance

Retiree

$3,000

$6,000

$3,500

$7,000

Retiree Plus2

$6,000

$12,000

$7,000

$14,000

25%

40%

30%

50%

Retiree

$4,000

$8,000

$5,250

$10,500

Retiree Plus2

$8,000

$16,000

$10,500

$21,000

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

100%

D/C

100%

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

Telehealth

Amwell

D/C

D/C

$15 Copay

D/C

ID Cards

  • The Blue Cross and Blue Shield ID card will list your name only. Your dependents’ names, if applicable, will not be included on the card. Additional or replacement cards can be requested online or by contacting  Blue Cross and Blue Shield.

  • To request online, go to nebraskablue.com and click on “Member Log In” in the upper right corner.

  • Then select “Log In.” After logging into your account, click on “My Benefits”, then “Mail new ID card”.

Coordination of Benefits

If you or a family member is covered under a WoodmenLife Health Plan, as well as under other coverage (a spouse’s plan, for example), it may be necessary for the multiple plans to coordinate benefits. Coordination of Benefits does not apply to prescription drug claims.

Disclosures

  1. All Non-Medicare-Eligible family members must be enrolled in the same plan

  2. Retiree Plus means: Retiree + Child(ren), Retiree + Spouse or Retiree + Family

Customer Service: 1-800-225-3108
Monday – Thursday 7:00 a.m. to 5:00 p.m.
Friday 7:00 a.m. to 12:00 p.m. (Central Time)

This company was issued a secure rating by the A.M. Best Company
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WoodmenLife is a proud member of American Fraternal Alliance



© 2022 Woodmen of the World Life Insurance Society
Omaha, Nebraska

The information on this page is a partial description of benefits, limitations, exclusions, and other provisions of the group benefits provided by Woodmen of the World Life Insurance Society (WoodmenLife). If there is a difference between the information in this summary and the plan document for each plan, the plan documents govern. Eligibility requirements apply to each of the benefits offered, criteria may include employment status and/or individual qualifications. For more detailed information, refer to the Summary Plan Description of each plan. WoodmenLife may amend these plans at any time. The description of the plan is not a guarantee of benefits and should not be construed as such.

This is the Life is a registered service mark of Woodmen of the World Life Insurance Society.

This is a solicitation of insurance and an agent may contact you.

Securities are offered through Woodmen Financial Services, Inc. (WFS), 1700 Farnam Street, Omaha, NE 68102, 877-664-3332, member FINRA/SIPC, a wholly owned subsidiary of Woodmen of the World Life Insurance Society (collectively “WoodmenLife”). Securities other than the WoodmenLife Variable Annuity are issued by companies that are not affiliated with WoodmenLife. This material is intended for general use with the public. WFS is not providing investment advice for any individual or any individual situation, and you should not look to this material for any investment advice. WFS has financial interests that are served by the sale of these products or services.

WoodmenLife Extras are available to members. An individual becomes a member by joining our shared commitment to family, community and country, and by purchasing a WoodmenLife product. These extras are not contractual, are subject to change and have specific eligibility requirements.

Some WoodmenLife Extras include additional membership requirements including length of membership, number of qualifying members in household and/or a qualifying event.

Check out the background of Woodmen Financial Services, Inc. on FINRA’s BrokerCheck.

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A+ Financial Rating

This company was issued a A+ (Superior) rating by the A.M. Best Company, click for additional details. WoodmenLife has been awarded a rating of A+ (Superior), the second highest ranking out of 15, for its financial strength and operating performance in 2021 by A.M. Best, an independent rating company that is nationally recognized for its objective reporting and rating of insurers.

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