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Blue Cross Blue Shield Nebraska MA Core (HMO)

H3170 - 003 - 1

(3.5 / 5)

Blue Cross Blue Shield Nebraska MA Core (HMO) is a Medicare Advantage Plan by Blue Cross and Blue Shield of Nebraska.

This page features plan details for 2025 Blue Cross Blue Shield Nebraska MA Core (HMO) H3170 – 003 – 1 available in Omaha/Lincoln Metro Area and Central Nebraska.

Locations

Blue Cross Blue Shield Nebraska MA Core (HMO) is offered in the following locations.

Cass County, Nebraska

Dodge County, Nebraska

Douglas County, Nebraska

Click to see more locations

Plan Overview

Blue Cross Blue Shield Nebraska MA Core (HMO) offers the following coverage and cost-sharing.

Insurer:	Blue Cross and Blue Shield of Nebraska
Health Plan Deductible:	$0
MOOP:	$3,900 In-network
Drugs Covered:	Yes

Ready to sign up for Blue Cross Blue Shield Nebraska MA Core (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.

Blue Cross Blue Shield Nebraska MA Core (HMO) qualifies for a monthly Medicare Give Back Benefit of $1.00.

Premium Reduction:

$1.00

Premium Breakdown

Blue Cross Blue Shield Nebraska MA Core (HMO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$0.00	$0.00	$1.00	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Blue Cross Blue Shield Nebraska MA Core (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$0.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic	$4.00 Copay	$4.00 Copay	$4.00 Copay
2) Generic	$14.00 Copay	$14.00 Copay	$14.00 Copay
3) Preferred Brand	$47.00 Copay	$47.00 Copay	$47.00 Copay
4) Non-Preferred Drug	$100.00 Copay	$100.00 Copay	$100.00 Copay
5) Specialty Tier		33.00% Coinsurance	33.00% Coinsurance

60 Day

Tier	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic	$8.00 Copay	$8.00 Copay	$8.00 Copay
2) Generic	$28.00 Copay	$28.00 Copay	$28.00 Copay
3) Preferred Brand	$94.00 Copay	$94.00 Copay	$94.00 Copay
4) Non-Preferred Drug	$200.00 Copay	$200.00 Copay	$200.00 Copay
5) Specialty Tier

90 Day

Tier	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic	$12.00 Copay		$12.00 Copay
2) Generic	$42.00 Copay		$42.00 Copay
3) Preferred Brand	$141.00 Copay	$131.00 Copay	$141.00 Copay
4) Non-Preferred Drug	$300.00 Copay	$290.00 Copay	$300.00 Copay
5) Specialty Tier

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Blue Cross Blue Shield Nebraska MA Core (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: No

Comprehensive Dental

Endodontics
- In-Network: No Coins – No Co pay (Limits Apply)
Implant Services
- In-Network: No Coins – No Co pay (Limits Apply)
Maxillofacial Prosthetics
- In-Network: No Coins – No Co pay (Limits Apply)
Oral and Maxillofacial Surgery
- In-Network: No Coins – No Co pay (Limits Apply)
Periodontics
- In-Network: No Coins – No Co pay (Limits Apply)
Prosthodontics, fixed
- In-Network: No Coins – No Co pay (Limits Apply)
Prosthodontics, removable
- In-Network: No Coins – No Co pay (Limits Apply)
Restorative Services
- In-Network: No Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – No Copay
Fluoride Treatment
- In-Network: No Coins – No Copay
Oral Exams
- In-Network: No Coins – No Copay
Other Diagnostic Dental Services
- In-Network: No Coins – No Copay (Limits Apply)
Other Preventive Dental Services
- In-Network: No Coins – No Copay (Limits Apply)
Prophylaxis (cleaning)
- In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

Lab services
- $0 copay (Authorization Required)
Diagnostic radiology services (e.g., MRI)
- $195 copay (Authorization Required)
Diagnostic tests and procedures
- $30-350 copay (Authorization Required)
Outpatient x-rays
- $25 copay (Authorization Required)

Doctor visits

Primary
- $0 copay
Specialist
- $35 copay per visit

Emergency care/Urgent care

Urgent care
- $55 copay per visit (always covered)
Emergency
- $125 copay per visit (always covered)

Foot care (podiatry services)

Routine foot care
- Not covered
Foot exams and treatment
- $35 copay

Ground ambulance

- $350 copay

Health plan deductible

- $0

Hearing

Hearing aids OTC
- Not covered
Medicare-Covered Hearing Exam
- $0-35 copay
Fitting/evaluation
- $0 copay (Limits Apply)
Hearing aids
- $395-1,595 copay (Limits Apply)

Inpatient hospital coverage

- $400 per day for days 1 through 4
  $0 per day for days 5 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $3,900 In-network

Medical equipment/supplies

Durable medical equipment (e.g., wheelchairs, oxygen)
- 20% coinsurance per item (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- 20% coinsurance per item (Authorization Required)
Diabetes supplies
- 0-20% coinsurance per item

Medicare Part B drugs

Chemotherapy
- 0-20% coinsurance (Authorization Required)
Other Part B drugs
- 0-20% coinsurance (Authorization Required)

Mental health services

Inpatient hospital – psychiatric
- $420 per day for days 1 through 4
  $0 per day for days 5 through 90 (Authorization Required)
Outpatient group therapy visit
- $35 copay
Outpatient group therapy visit with a psychiatrist
- $35 copay
Outpatient individual therapy visit
- $35 copay
Outpatient individual therapy visit with a psychiatrist
- $35 copay

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $350 copay per visit (Authorization Required)

Preventive care

- $0 copay

Rehabilitation services

Physical therapy and speech and language therapy visit
- $35 copay (Authorization Required)
Occupational therapy visit
- $35 copay (Authorization Required)

Skilled Nursing Facility

- $0 per day for days 1 through 20
  $186 per day for days 21 through 53
  $0 per day for days 54 through 100 (Authorization Required)

Transportation

- Not covered

Vision

Eyeglass lenses
- $0 copay (Limits Apply)
Upgrades
- $0 copay (Limits Apply)
Eyeglasses (frames and lenses)
- $0 copay (Limits Apply)
Contact lenses
- $0 copay (Limits Apply)
Eyeglass frames
- $0 copay (Limits Apply)
Other
- Not covered
Routine eye exam
- $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

- Covered