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 | $616.72 | $1,487.93 | $700.11 |
20 to 29 years | $1,180.02 | $1,779.83 | $700.11 |
5 to 19 years | — | $1,779.83 | $700.11 |
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
All Non-Medicare-Eligible family members must be enrolled in the same plan
Retiree Plus means: Retiree + Child(ren), Retiree + Spouse or Retiree + Family