36-054-08 98-510 5/2014 University of Nebraska - Student Plan $500 2014/2015 Academic Year
Schedule of Benefits Summary Health Plan
University Name: University of Nebraska - Student Plan Benefit Year: 2014/2015 Academic Year (see attached)
Payment for Services In-network
Provider
Out-of-network Provider Covered Services are reimbursed based on the Allowable Charge. Blue Cross and Blue Shield of Nebraska In-network Providers have agreed to accept the benefit payment as payment in full, not including Deductible, Coinsurance and/or Copayment amounts and any charges for non-covered services, which are the Covered Person’s responsibility. That means In-network providers, under the terms of their contract with Blue Cross and Blue Shield, can’t bill for amounts over the Contracted Amount. Out-of-network Providers can bill for amounts over the Out-of-network Allowance.
Covered Services provided by the University Student Health Clinics at UNK, UNL, UNO and UNMC will be covered with no cost-share to members, except as shown under the Prescription Drugs section.
Deductible (Embedded*)
Individual $500 $1,000
Family $1,000 $2,000
Coinsurance
Covered Person Pays 20% 50%
Plan Pays 80% 50%
Out-of-pocket Limit (Embedded*)
(includes Deductible, Coinsurance and Copays)
Individual $2,500 $ 5,000
Family $5,000 $10,000
Once the annual Out-of-pocket Limit is reached, most Covered Services are payable by the plan at 100% for the rest of the Benefit Year. In-network and Out-of-network Deductible and Out-of-pocket Limits cross accumulate. All other limits (days, visits, sessions, dollar amounts, etc.) do cross accumulate between In-network and Out-of-network, unless noted differently.
*Embedded – If you have single coverage, you only need to satisfy the individual Deductible and Out-of-pocket Limit amounts. If you have family coverage, no one family member contributes more than the individual amount. Family members may combine their covered expenses to satisfy the required family Deductible and Out-of-pocket amounts.
36-054-08 98-510 5/2014 University of Nebraska - Student Plan $500 2014/2015 Academic Year
Covered Services – Illness or Injury In-network
Provider
Out-of-network Provider Physician Office
Primary Care Physician Office Services $20 Copay Deductible and Coinsurance
Specialist Physician Office Services $30 Copay Deductible and Coinsurance Primary Care Physician benefits include the office visit provided by a physician who has a majority of his or her practice in internal or general medicine, obstetrics/gynecology, general pediatrics or family practice. A Certified physician assistant and a Certified nurse practitioner are covered in the same manner as a Primary Care Physician.
Specialist Physician benefits include the office visits provided by a physician who is not a Primary Care Physician.
Physician Professional Services
(Outpatient and Inpatient Services) Deductible and Coinsurance Deductible and Coinsurance Urgent Care Facility Services (a single Copay applies to
each urgent care visit) $75 Copay Deductible and Coinsurance
Emergency Care Services (Services received in a Hospital emergency room setting)
Facility $300 Copay then Deductible
and Coinsurance In-network level of benefits
Professional Services Deductible and Coinsurance In-network level of benefits (Copayment is waived if admitted to the hospital within 24
hours for the same diagnosis)
Outpatient Hospital or Facility Services Deductible and Coinsurance Deductible and Coinsurance Inpatient Hospital or Facility Services Deductible and Coinsurance Deductible and Coinsurance
Preventive Services In-network
Provider
Out-of-network Provider Preventive Services
Affordable Care Act (ACA) required
preventive services (may be subject to limits that include, but are not limited to, age, gender, and frequency)
Plan Pays 100% Deductible and Coinsurance
Other covered preventive services not
required by ACA Plan Pays 100% Deductible and Coinsurance
Immunizations
Pediatric (up to age 7) Plan Pays 100% Coinsurance
Age 7 and older Plan Pays 100% Deductible and Coinsurance
Related to an illness Same as any other illness Same as any other illness
Pre-classroom Enrollment In-network
Provider
Out-of-network Provider Immunizations and Testing (Services required by
University prior to admission) Plan Pays 100% Plan Pays 100%
36-054-08 98-510 5/2014 University of Nebraska - Student Plan $500 2014/2015 Academic Year Mental Illness and/or Substance Dependence and Abuse
Covered Services
In-network Provider
Out-of-network Provider
Inpatient Services Deductible and Coinsurance Deductible and Coinsurance
Outpatient Services
Office Services $20 Copay Deductible and Coinsurance
All Other Outpatient Items & Services Deductible and Coinsurance Deductible and Coinsurance Emergency Care Services (Services received in a Hospital
emergency room setting)
Facility $300 Copay then Deductible
and Coinsurance In-network level of benefits
Professional Services Deductible and Coinsurance In-network level of benefits (Copayment is waived if admitted to the hospital within 24
hours for the same diagnosis)
Transgender Assignment/Reassignment In-network
Provider
Out-of-network Provider
Inpatient Services Deductible and Coinsurance Deductible and Coinsurance
Outpatient Services
Office Services $20 Copay Deductible and Coinsurance
All Other Outpatient Items & Services Deductible and Coinsurance Deductible and Coinsurance Emergency Care Services (Services received in a Hospital
emergency room setting)
Facility $300 Copay then Deductible
and Coinsurance In-network level of benefits
Professional Services Deductible and Coinsurance In-network level of benefits (Copayment is waived if admitted to the hospital within 24
hours for the same diagnosis)
Note: Surgery and related Covered Services limited to $75,000 while covered
36-054-08 98-510 5/2014 University of Nebraska - Student Plan $500 2014/2015 Academic Year Other Covered Services – Illness or Injury In-network
Provider
Out-of-network Provider Accident Related Care (Supplemental Benefit)
(limited to $2,000 per person per Benefit Year, for charges in excess of this amount see the applicable service category)
Plan Pays 100% In-network level of benefits
Ambulance (to the nearest facility for appropriate care)
Ground Ambulance Deductible and Coinsurance In-network level of benefits
Air Ambulance Deductible and Coinsurance
Deductible and Coinsurance (In-network level of benefits if due to an emergency) Durable Medical Equipment Deductible and Coinsurance Deductible and Coinsurance Home Health Care
Skilled Nursing Care (limited to 8 hours per
day Deductible and Coinsurance Deductible and Coinsurance
Home Health Aide (limited to 60 days per
Benefit Year) Deductible and Coinsurance Deductible and Coinsurance
Respiratory Care (limited to 60 days per
Benefit Year) Deductible and Coinsurance Deductible and Coinsurance
Hospice Services Deductible and Coinsurance Deductible and Coinsurance Independent Laboratory
Diagnostic Plan Pays 100%
In-network level of benefits
Preventive Same as Preventive Services
In-network level of benefits
Same as Preventive Services In-network level of benefits Intercollegiate Sports Injuries (limited to UNK and UNO
students and subject to $20,000 per person per Benefit Year)
Same as any other illness Same as any other illness Pediatric Dental (up to age 19)
Preventive and Diagnostic Deductible and Coinsurance Deductible and Coinsurance
Maintenance and Simple Restorative Deductible and Coinsurance Deductible and Coinsurance
Complex Restorative Deductible and Coinsurance Deductible and Coinsurance
Orthodontic Services (24 month wait applies)
Deductible then Covered Person pays 70%
Deductible then Covered Person pays 70%
NOTE: Age and frequency limits apply Dental Provider Network – Dental GRID
Pregnancy and Maternity Services (prenatal/postnatal
care and delivery) Deductible and Coinsurance Deductible and Coinsurance
Skilled Nursing Facility
Deductible and Coinsurance Deductible and Coinsurance (limited to 60 days per Benefit Year)
36-054-08 98-510 5/2014 University of Nebraska - Student Plan $500 2014/2015 Academic Year Other Covered Services – Illness or Injury In-network
Provider
Out-of-network Provider
Temporomandibular and Craniomandibular Joint Disorder Deductible and Coinsurance Deductible and Coinsurance Therapy & Manipulations
Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Benefit Year)
Deductible and Coinsurance Deductible and Coinsurance
Chiropractic or osteopathic manipulative treatments or adjustments (combined limit to 20 sessions per Benefit Year)
Deductible and Coinsurance Deductible and Coinsurance Vision Exams
Diagnostic (to diagnose an illness) See Physician Office Services See Physician Office Services
Preventive (routine exam including refraction)
- Pediatric (up to age 19) See Pediatric Vision Services Section
See Pediatric Vision Services Section
- Adult (age 19 and over) limited to
$50 per Benefit Year
Plan Pays 100% up to $50 per Benefit Year then Not
Covered
Plan Pays 100% up to $50 per Benefit Year then Not
Covered
All Other Covered Services Deductible and Coinsurance Deductible and Coinsurance
Pediatric Vision Services In-network
Provider
Out-of-network Provider Pediatric Vision Services are limited to Covered Persons up to age 19
Vision Examination (including refraction and dilation,
limited to one exam per Benefit Year) Deductible and Coinsurance Deductible and Coinsurance Eyeglass Frames/Lenses or Contacts
(limited to one set of frames and eyeglass lenses per Benefit Year or one purchase of Contact lenses per Benefit Year)
Lenses Deductible then Covered
Person pays 50% In-network level of benefits
Frames Deductible then Covered
Person pays 50% In-network level of benefits
Contact Lenses (including evaluation and fitting, when in lieu of eyeglasses)
Deductible then Covered
Person pays 50% In-network level of benefits Medically Necessary Contact Lenses (in lieu of eyeglasses,
for specific conditions)
NOTE Certification required in excess of $600
Deductible then Covered
Person pays 50% In-network level of benefits Low Vision Services and Aids
Comprehensive low vision evaluation (limited
to one every ( 5 ) Benefit Years) Deductible and Coinsurance Deductible and Coinsurance
Follow-up low vision care (limited to four
visits in any (5) Benefit Year period) Deductible and Coinsurance Deductible and Coinsurance
Low vision aids Deductible then Covered
Person pays 50% In-network level of benefits NOTE: Certification required for low vision Services and
aids
36-054-08 98-510 5/2014 University of Nebraska - Student Plan $500 2014/2015 Academic Year
Prescription Drugs University of
Nebraska – Lincoln Health Center
Pharmacy
In-network Provider
Out-of network Provider
Retail and Mail order – per 30-day supply
Generic drugs $5 Copay $10 Copay
In-network level of benefits +25%
Penalty
Formulary Brand Name Drugs $30 Copay $40 Copay
In-network level of benefits +25%
Penalty
Non-formulary Brand Name Drugs $80 Copay $80 Copay
In-network level of benefits +25%
Penalty NOTE: A 90-day supply is available at a retail Extended Supply Network pharmacy subject to 3 copays.
Specialty drugs
(specialty drugs must be purchased through a designated specialty pharmacy after two fills)
$100 Copay $100 Copay Not Covered
Contraceptives • Formulary
- Generic Plan Pays 100% Plan Pays 100% 25% Penalty
- Brand Plan Pays 100% Plan Pays 100% 25% Penalty
• Non-formulary
- Generic Same as any other Generic Drug
- Brand Same as any other Non-formulary Brand Name
- Ogestrel 0.5/50 $30 Copay $40 Copay
In-network level of benefits +25%
Penalty
- Nuvaring Plan Pays 100% Plan Pays 100% 25% Penalty
Please note: This Schedule of Benefits Summary is intended to provide you with a brief overview of your benefits. It is not a contract and should not be regarded as one. For more complete information about your plan, including benefits, exclusions and contract limitations, please refer to the master group contract. In the event there are discrepancies between this document and the contract, the terms and conditions of the contract will govern.
36-054-08 98-510 5/2014 University of Nebraska - Student Plan $500 2014/2015 Academic Year University of Nebraska Medical Center
Benefit Year for the 2014/2015 Academic Year
Program Benefit Year
Allied Health, PA1, PT1, PT2, PT3, Medical Nutrition Perfusion 5 & 6, Cytotechnology, Medicine 1 & 2, Pharmacy 1, 2 & 3, Radiology, Oncology, Nursing, Post MS, graduate, RSTE Medical Family Therapy
August 25, 2014 through August 24, 2015
Accelerated Nursing May 12, 2014 through May 11,2015
Clinical Lab Science May 29, 2014 through May 28, 2015
New 4th Year Pharmacy (4th Year Student enrolling in plan for first time)
May 12, 2014 through May 11,2015
PA 2 & 3 September 2, 2014 through September 1, 2015
Post Graduate Dental Certificate July 1, 2014 through June 30, 2015
Post Graduate July 1, 2014 through June 30, 2015
New 3rd & 4th Year Medical Student July 7, 2014 through July 6, 2015 Visiting Scholars/Miscellaneous May 1, 2014 through April 30, 2015
University of Nebraska - Kearney Benefit Year for the 2014/2015 Academic Year
Program Benefit Year
Enrolled Students August 1, 2014 through July 31, 2015
Visiting Scholars/Miscellaneous May 1, 2014 through April 30, 2015 University of Nebraska - Lincoln
Benefit Year for the 2014/2015 Academic Year
Program Benefit Year
Enrolled Students August 14, 2014 through August 13, 2015
Visiting Scholars/Miscellaneous May 1, 2014 through April 30, 2015 University of Nebraska - Omaha
Benefit Year for the 2014/2015 Academic Year
Program Benefit Year
Enrolled Students August 14, 2014 through August 13, 2015
Visiting Scholars/Miscellaneous May 1, 2014 through April 30, 2015