Nebraska HeartlandBlue Gold $0 PCP Visit 1500 PSBC

29678NE1470011
Gold
EPO

Nebraska HeartlandBlue Gold $0 PCP Visit 1500 PSBC is a Gold EPO plan by Blue Cross and Blue Shield of Nebraska.

IMPORTANT: You are viewing the 2023 version of Nebraska HeartlandBlue Gold $0 PCP Visit 1500 PSBC 29678NE1470011. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Nebraska HeartlandBlue Gold $0 PCP Visit 1500 PSBC is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Nebraska HeartlandBlue Gold $0 PCP Visit 1500 PSBC 29678NE1470011.
Insurer: Blue Cross and Blue Shield of Nebraska
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 29678NE1470011

Cost-Sharing Overview

Nebraska HeartlandBlue Gold $0 PCP Visit 1500 PSBC offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Nebraska HeartlandBlue Gold $0 PCP Visit 1500 PSBC?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Nebraska HeartlandBlue Gold $0 PCP Visit 1500 PSBC offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Nebraska HeartlandBlue Gold $0 PCP Visit 1500 PSBC covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency Services
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency Services
National Network: No

Additional Benefits and Cost-Sharing

Nebraska HeartlandBlue Gold $0 PCP Visit 1500 PSBC includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$0.00 100.00%
Specialist Visit
Covered
30.00% Coinsurance after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
30.00% Coinsurance after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
30.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
30.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
30.00% Coinsurance after deductible 100.00% The Covered Person must have a life expectancy of six months or less as documented in writing by the attending Physician. The Hospice Services must be ordered by a Physician. Services provided must be appropriate for palliative support or management of a Covered Person with terminal medical Illness.
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$50.00 100.00%
Home Health Care Services
Covered
30.00% Coinsurance after deductible 100.00%60 Days per Year
Emergency Room Services
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
30.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
30.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
30.00% Coinsurance after deductible 100.00%60 Days per Year
Prenatal and Postnatal Care
Covered
30.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
30.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
No Charge 100.00%
Mental/Behavioral Health Inpatient Services
Covered
30.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
No Charge 100.00%
Substance Abuse Disorder Inpatient Services
Covered
30.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$3.00 100.00%
Preferred Brand Drugs
Covered
$100.00 100.00%
Non-Preferred Brand Drugs
Covered
55.00% Coinsurance after deductible 100.00%
Specialty Drugs
Covered
60.00% Coinsurance after deductible 100.00%
Outpatient Rehabilitation Services
Covered
30.00% Coinsurance after deductible 100.00%45 Visit(s) per Year The limit is 45 visits per year This limit is shared by Physical Occupational, Speech Therapy and Outpatient Rehabilitation
Habilitation Services
Covered
30.00% Coinsurance after deductible 100.00%45 Visit(s) per Year The limit is 45 visits per year This limit is shared by Physical Occupational, Speech Therapy and Outpatient Habilitative Services
Chiropractic Care
Covered
30.00% Coinsurance after deductible 100.00%20 Visit(s) per Year
Durable Medical Equipment
Covered
30.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
30.00% Coinsurance after deductible 100.00% covered up to age 19 limited to $3,000 every 48 months
Imaging (CT/PET Scans, MRIs)
Covered
30.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
30.00% Coinsurance after deductible 100.00%1 Visit(s) per Year
Eye Glasses for Children
Covered
50.00% Coinsurance after deductible 100.00%1 Item(s) per Year In-network deductible applies to both In and Out-Of-Network
Dental Check-Up for Children
Covered
30.00% Coinsurance after deductible 100.00%1 Visit(s) per 6 Months
Rehabilitative Speech Therapy
Covered
30.00% Coinsurance after deductible 100.00%45 Visit(s) per Year The limit is 45 visits per year This limit is shared by Physical Occupational, Speech Therapy and Outpatient Rehabilitation
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
30.00% Coinsurance after deductible 100.00%45 Visit(s) per Year The limit is 45 visits per year This limit is shared by Physical Occupational, Speech Therapy and Outpatient Rehabilitation
Well Baby Visits and Care
Covered
30.00% Coinsurance after deductible 100.00%
Laboratory Outpatient and Professional Services
Covered
30.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
30.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Covered
30.00% Coinsurance after deductible 100.00%
Orthodontia – Child
Covered
70.00% Coinsurance after deductible 100.00% There is a 24 month waiting period for this benefit
Major Dental Care – Child
Covered
30.00% Coinsurance after deductible 100.00%
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
30.00% Coinsurance after deductible 100.00%
Accidental Dental
Covered
30.00% Coinsurance after deductible 100.00%
Dialysis
Covered
30.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
30.00% Coinsurance after deductible 100.00% Assumption most services are in office
Chemotherapy
Covered
30.00% Coinsurance after deductible 100.00%
Radiation
Covered
30.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
30.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
30.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
30.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
30.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered only for diabetes or ACA-required preventive care
Reconstructive Surgery
Covered
30.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Covered
30.00% Coinsurance after deductible 100.00%
Dental Anesthesia
Covered
30.00% Coinsurance after deductible 100.00% Based on most common prescription tier
Off Label Prescription Drugs
Covered
30.00% Coinsurance after deductible 100.00%
Diabetes Care Management
Covered
30.00% Coinsurance after deductible 100.00%
Tier 2 Generic Drugs
Covered
$10.00 100.00%
Tier 2 Specialty Drugs
Covered
70.00% Coinsurance after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Nebraska HeartlandBlue Gold $0 PCP Visit 1500 PSBC preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Nebraska HeartlandBlue Gold $0 PCP Visit 1500 PSBC including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Nebraska HeartlandBlue Gold $0 PCP Visit 1500 PSBC?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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