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ARMOR HEALTHHealth Insurance for Individuals and Families

2 | ARMOR HEALTH ARMOR HEALTH | 3

With Armor Health you get:

• Low in-network deductibles

• In-network preventive care covered at 100%

• Child-only coverage

• Telehealth coverage

• Preferred generic drugs at no cost

• Access to a nationwide network of doctors and hospitals

• Coverage for pre-existing conditions1

• Experienced, local customer service

• And more

Armor Health is a great option for people who need:

• Flexibility, offering one month of coverage or more

• Affordability

• Individual coverage for employees

• An alternative to COBRA coverage

ARMOR HEALTH

Armor Health provides flexible coverage for individuals and families. Whether you need coverage for one month or many, Armor Health offers a cost-effective alternative to Affordable Care Act (ACA) plans.

1Armor health policies have a 12-month waiting period for pre-existing conditions. After the initial 12-month coverage period, members who re-enroll for Armor Health with no lapse in Armor Health coverage will have the pre-existing waiting period waived.

Through bumps and broken bones, tests and treatments, trauma and triumphs,

BCBSNE is there with you. For more than 80 years, we have ensured access to the

providers you trust, coverage for the care you need and support from a team that’s

right here in Nebraska.

COUNT ON US TO BE THERE


*Source: BCBSNE statistics, June 19, 2020

STATEWIDE ACCESSWith BCBSNE coverage you can have peace of mind knowing you have access to hospitals, doctors and other health care providers you trust. NEtwork BLUE is made up of 96% of Nebraska’s doctors and 99% of the state’s non-governmental acute care hospitals.* That makes obtaining in-network care easy and convenient.

For a complete list of hospitals and providers, visit: NebraskaBlue.com/Networks

Nationwide Access

BCBSNE members have access to a national network called the BlueCard® Program. The BlueCard Program gives members access to doctors and hospitals almost everywhere within the United States. Members are covered whether they need care in urban or rural areas.

Outside of the United States, members have access to doctors and hospitals in nearly 200 countries and territories around the world through the Blue Cross Blue Shield Global® Core Program.

accessIN ALL

50STATES

WORLDT H EAND AROUND

Armor Health covers most Essential Health Benefits, including:

Prescription drugs

Outpatient care, including physician

office visits

Inpatient hospitalization

Preventive services covered at 100%

in network

Outpatient mental health and substance abuse

Habilitative and rehabilitative

services

Emergency services, including

ambulance services

Diagnostic and preventive laboratory

Total Care

When looking for a physician, we encourage you to consider Total Care providers who are recognized for helping their patients get high-quality care in the right place at the right times, keep costs down and achieve better health outcomes. Look for the Total Care mark when searching for providers at NebraskaBlue.com/Find-A-Doctor.

Blue Distinction® Center

If you or a family member will need a procedure or treatment at a medical facility, consider a Blue Distinction Center. These facilities have been awarded for expertise in delivering safe, effective and affordable specialty care. To find a Blue Distinction Center, visit BCBS.com/Blue-Distinction-Center/Facility.


COMPARE POLICIESFind the policy that‘s right for you

Three Armor Health options make it easy to find one that fits your budget and coverage needs. All Armor Health options cover pre-existing conditions (after a 12-month waiting period) and offer out-of-network coverage.

Option 1 Option 2 Option 3In Network Out of Network In Network Out of Network In Network Out of Network

Deductible (Embedded*)

Individual $2,500 $25,000 $5,000 $50,000 $7,500 $75,000

Family $5,000 $50,000 $10,000 $100,000 $15,000 $150,000

Coinsurance (Amount you pay)

20% 50% 20% 50% 20% 50%

Out-of-pocket Maximum (Embedded*)

Individual $4,500 $45,000 $7,000 $70,000 $9,500 $95,000

Family $9,000 $90,000 $14,000 $140,000 $19,000 $190,000

Lifetime Maximum

$1,000,000 $1,000,000 $1,000,000 $1,000,000 $1,000,000 $1,000,000

Preventive Care

Preventive Care Services Plan Pays 100% Deductible & Coinsurance Plan Pays 100% Deductible &

Coinsurance Plan Pays 100% Deductible & Coinsurance

Physician Office

Primary Care Physician Office $30 Copay Deductible & Coinsurance $30 Copay Deductible &

CoinsuranceDeductible & Coinsurance

Deductible & Coinsurance

Specialist Physician Office $60 Copay Deductible & Coinsurance $60 Copay Deductible &



Telehealth $10 Copay Not Covered $10 Copay Not Covered Deductible & Coinsurance Not Covered

Other Covered Outpatient Services







Emergency Care

Urgent Care Facility Services$75 First 3 Visits

then Deductible & Coinsurance


$75 First 3 Visits then Deductible &




Emergency Care Services Deductible & 50% Coinsurance

In-network Level of Benefits

Deductible & 50% Coinsurance




Ambulance Services Deductible & Coinsurance






Mental Illness and/or Substance Dependence and Abuse Services

Telehealth Deductible & Coinsurance Not Covered Deductible &

Coinsurance Not Covered Deductible & Coinsurance Not Covered

Outpatient Deductible & Coinsurance






Office Services Deductible & Coinsurance






Emergency Care Services Deductible & 50% Coinsurance






Inpatient and Outpatient Hospital or Facility ServicesDeductible & Coinsurance






*Embedded deductible and out of pocket means for family coverage, family members may combine their covered expenses to satisfy the required family deductible or out-of-pocket maximum. No one family member contributes more than the individual deductible or out-of-pocket maximum amount to satisfy the family deductible or out-of-pocket maximum.

1Copays do not apply to the out-of-pocket maximum2Members pay 100% of BCBSNE discounted rate and these amounts do not apply to the out-of-pocket maximum.

In Network Out of Network

Pharmacy Benefits1

Preferred Generic Drugs $0 copay1

Walgreens

Baker’s

Kohll’s

U Save

Kmart

and more

Not Covered

CVS

Target

Non-preferred Generic Drugs $75 copay1 Not Covered

Preferred Brand-name Drugs Member Pays 100%2 Not Covered

Non-preferred Brand-name Drugs Member Pays 100%2 Not Covered

Specialty Drugs Member Pays 100%2 Not Covered

Pharmacy

Network J, Prescription Drug List (PDL) 40Prescription drug coverage is available to you through our Rx Nebraska Prescription Drug Program with our pharmacy benefit manager, Prime Therapeutics, Inc.

For a complete listing of in-network pharmacies in Network J, or to view your prescription drug list (PDL) 40, visit NebraskaBlue.com/Pharmacy.

Extended Supply Network Pharmacy BenefitBCBSNE offers our Extended Supply Network (ESN) retail pharmacy benefit to all Armor Health members. This benefit allows you to get a 90-day supply of prescription medications from a retail pharmacy (if allowed by your prescrip tion).† Non-ESN retail pharmacies are limited to a 30-day supply.

You must pay three copays at one time to purchase a 90-day supply.

Using the ESN retail pharmacy benefit for up to a 90-day supply of medications means fewer trips to the pharmacy, saving you time.

A list of ESN retail pharmacies is available under the Pharmacy Benefits tab at myNebraskaBlue.com/ToolsandResources, or by calling our Member Services department at the number on the back of your member ID card.

†Excludes specialty drugs.

Retail PharmaciesTake your prescription to an in-network pharmacy to be filled and show the pharmacist your member ID card. You will then pay the applicable copay amount.

Home Delivery If you choose to use Express Scripts® Pharmacy, you may order up to a 90-day supply of maintenance medication by paying the applicable copay amount for each 30-day supply.

PreauthorizationAs part of our efforts to address the serious issue of escalating costs and to continue to provide members with access to quality and cost-effective pharmacy care, we require benefits for certain prescription products to be preauthorized. Those products include gastro-intestinal protection NSAIDs, proton pump inhibitors, diabetic test strips and testosterone preauthorization programs. For a list of additional products requiring preauthorization, visit NebraskaBlue.com/DrugList.

Prime Therapeutics LLC is an independent company providing pharmacy benefit management services for Blue Cross and Blue Shield of Nebraska

Express Scripts Pharmacy is a pharmacy that is contracted to provide mail pharmacy services to members of Blue Cross and Blue Shield of Nebraska.

Express Scripts Pharmacy is a trademark of Express Scripts Strategic Development, Inc.


ADDITIONAL COVERAGE OPTIONS AVAILABLE Purchase supplemental coverage to compliment your Armor Health benefits. These products are available for purchase separately.

Dental

• Stay on top of your dental health — DentalEssentials dental coverage may be purchased separately or purchase with an Armor Health policy to waive the 6-month waiting period for B services.

Accident and Critical Illness

Protect yourself from the unexpected with plans from LifeSecure offered through BCBSNE

• Accident Insurance• Critical Illness Insurance • Hospital Recovery Insurance

Travel Medical Insurance

• Get additional coverage when you travel abroad. GeoBlue® travel medical insurance can be purchased separately.

A Range of OptionsWith three DentalEssentials options, you can select a plan that best meets your coverage needs and your budget.

Billing EaseWith DentalEssentials, paying your monthly premiums is simple. If you have health insurance with us, you’ll receive a single bill for both your medical and dental benefits.1 You can also visit myNebraskaBlue.com to view the status of your claims, find a dentist and manage your account.

One of the Largest PPO Dental Networks in the NationOur DentalEssentials members and their covered dependents will receive in-network benefits whenever they use dentists in our network. In-network dentists are located in Nebraska and throughout the nation.

The dental network consists of multiple Blue Cross and Blue Shield Plans that, when combined, offers members one of the largest PPO dental networks in the nation. It

provides members with lower out-of-pocket costs and broad access to participating dentists.

In-network dentists have agreed to accept our payment for covered services as payment in full, except for any deductible or coinsurance amounts and charges for noncovered services, which are the member’s responsibility. That means that our network of providers, under the terms of their contract with us, can’t bill you for amounts over our benefit allowance.

However, out-of-network dentists can bill members for amounts in excess of the benefit allowance. For example: Susan went to an out-of-network dentist for a covered routine dental examination (a Coverage A service). Because the dentist billed more than the benefit allowance, Susan is responsible for the difference between the benefit allowance and the dentist’s billed charge.

OPTIONAL DENTAL COVERAGE WITH DENTALESSENTIALS

Three Plan OptionsDental coverage that meets your needs.

Please note: DentalEssentials does not cover services for orthodontic dentistry.

For additional information on DentalEssentials coverage, visit NebraskaBlue.com/Dental

1When the primary insured for both individual health and dental is the same. 2Coinsurance is based on the allowable charge for a covered service. Generally, the allowable charge for covered services by in-network providers will be the contract amount. The allowable charge for covered services by out-of-network providers will be based on the contracted amount for Nebraska providers or an amount determined by the on-site plan for out-of-area providers.3Waived for customers purchasing an Armor Health policy at the same time as a DentalEssentials plan.

Preventive Plus Enhanced Premier

Deductible $50 Per Person Per Calendar Year

$100 Per Person Per Calendar Year

$100 Per Person Per Calendar Year

Calendar Year Maximum $1,000 Per Person Per Calendar Year

$1,500 Per Person Per Calendar Year

$2,000 Per Person Per Calendar Year

Coinsurance2 (What You Pay)

Coverage A ServicesIn-network: 0%

(deductible waived)Out-of-network: 20%

In-network: 0% (deductible waived)

Out-of-network: 20%

In-network: 0% (deductible waived)

Out-of-network: 20%

Coverage B Services (6-Month Waiting Period3)

In-network: 20%Out-of-network: 30%



Coverage C Services (12-Month Waiting Period)

In-network and Out-of-network: 50%




Protect yourself from the unexpected with new supplemental products from LifeSecure Insurance Company. Learn more about how Accident, Critical Illness, and Hospital Recovery Insurance plans can help protect you from unexpected medical expenses.

OPTIONAL SUPPLEMENTAL INSURANCE PLANS

Accident InsurancePersonal accident insurance from LifeSecure pays cash benefits following an accidental injury regardless of any other insurance you may have.

Critical Illness Insurance Critical illness insurance from LifeSecure provides a lump sum cash benefit if you are diagnosed with a covered condition, such as a heart attack, stroke or cancer.

Hospital Recovery InsuranceHospital Recovery insurance from LifeSecure assists in the recovery phase following a hospital stay by paying cash benefits for a qualified inpatient hospitalization or care received in an observation unit.

Learn more or apply for coverage at NebraskaBlue.com/LifeSecure

OPTIONAL TRAVEL MEDICAL INSURANCE WITH GEOBLUE®

Whether you are traveling abroad for business or pleasure, leave home feeling confident that GeoBlue travel medical insurance is available to you. If you were to get sick or injured, you could be responsible for significant out-of-pocket costs. The cost of a medical evacuation could be staggering if you need to be transported back to the U.S. GeoBlue will get you the help you need when you need it.

Why choose GeoBlue?Traditional health insurance, including Medicare, often provides little to no coverage for medical care while traveling outside the United States. GeoBlue’s 24/7 customer support included with each plan, online or over the phone and offers:

Assistance with both non-emergency and emergency care, as well as medical evacuations

Direct pay options – no upfront payments for medical treatments and no claims to submit (GeoBlue pays the provider directly)

Access to an elite network of English-speaking doctors in nearly 200 countries

GeoBlue plans require a primary health insurance plan. A primary plan is a group health insurance plan, an individual health insurance plan or a governmental health plan (e.g. Medicare).

NOTE: Medicaid and VA health plans do not constitute primary health insurance.

GeoBlue is the trade name of Worldwide Insurance Services, LLC (Worldwide Services Insurance Agency, LLC in California and New York), an independent licensee of the Blue Cross and Blue Shield Association.

GeoBlue is the administrator of coverage provided under insurance policies issued by 4 Ever Life International Limited, Bermuda, an independent licensee of the Blue Cross and Blue Shield Association.

For additional information on GeoBlue, visit NebraskaBlue.com/GeoBlue

LifeSecure Insurance Company (Brighton, MI) underwrites and has sole financial responsibility for the Accident, Critical Illness, and Hospital Recovery insurance products. LifeSecure is an independent company providing ancillary products for Blue Cross and Blue Shield of Nebraska. LifeSecure products do not offer qualifying health coverage (“Minimum Essential Coverage” or “MEC”) that satisfies the health coverage under the Affordable Care Act. The termination or loss of one of these policies does not entitle you to a Special Enrollment Period to purchase a health benefit plan that qualifies as MEC outside of an Open Enrollment Period. These products have exclusions and limitations.


• See what your plan paid and what you may owe

• Review your claims history and track claims status

• Review your Explanation of Benefits (EOB) documents

Your Claims

Manage Your Health Care Online

Your personalized member account is available on your computer or mobile devices. You can access your benefits when and where you need them just by visiting myNebraskaBlue.com.

View your claims, compare costs and more – all at your convenience.

• Connect with MyPrime to find a pharmacy, review prescription costs or set your mail order services

Pharmacy

TOOLS AND PERKS AVAILABLE TO YOU

• View your benefits, copays, coinsurance and out-of-pocket costs

• Download your mobile ID card or request printed cards

Plan Benefits

• Find in-network doctors, hospitals and dentists

• Use the cost estimator to plan for and compare medical expenses

Doctors and Cost

Discounts

• View exclusive discounts

• Sign up to receive weekly specials

• View your premium statements and payment history

• Select your payment options and preferences

Billing Preferences

Save Time and Money with Telehealth

Telehealth, or virtual doctor visits, gives you access to quick, affordable care from home or wherever you are. Get convenient access to care that fits your life, any time, day or night. The cost per visit is often less than the cost of an in-person doctor visit.

How does telehealth work?

Talk with your primary care physician or other doctors about telehealth options they provide.

BCBSNE also offers telehealth access to certified, licensed and credentialed doctors through Amwell® — 24/7, on your computer, tablet or phone.

Amwell also offers e-prescriptions to your pharmacy of choice, when appropriate.

Telehealth is a convenient way to talk with a doctor about common conditions, such as:

Sinus infection

Cold

Flu

Fever

Rash

Abdominal pain

Pinkeye

Ear infection

Migraine

Sore throat

Mental and behavioral health services also availableWith telehealth behavioral health services, Amwell’s licensed therapists can provide treatment for the following conditions:

• Anxiety• Depression• Attention deficit hyper-activity disorder (ADHD)• Bereavement• Panic attacks• Obsessive-compulsive disorder (OCD)• Trauma/post-traumatic stress disorder (PTSD)• Stress• And more

Therapists are available by appointment from 7 a.m. to 11 p.m. local time, seven days a week.

Teletherapy like this may also be an option with your local care providers. Talk to your doctor.

To learn more, visit NebraskaBlue.com/Telehealth.

Blue365®

Blue365 is a national program that offers members health and wellness discounts and savings. Members can explore special offerings from leading national companies in these categories:

• Apparel and footwear• Fitness • Hearing and vision• Home and family• Nutrition• Personal care • Travel

Visit NebraskaBlue.com/Blue365 to learn more.

American Well is an independent company that provides telehealth services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross and Blue Shield Association.


General InformationApplications for Armor Health are subject to medical underwriting. Members covered under Armor Health must re-enroll for coverage after each 12-month coverage period and will be subject to medical underwriting.

Members over the age of 65 and/or eligible for Medicare are not eligible for coverage under Armor Health. If a subscriber turns age 65 while covered, their coverage will end the end prior to the month in which they turn 65.

Armor Health is available to Nebraska residents only. If a member moves out of state while covered under Armor Health, coverage will terminate. BCBSNE will provide the member with 30 days’ written notice of the termination.

Types of Enrollment Available Single Membership: Covers the subscriber only.

Child Only: Covers children ages 1 to 19; coverage is single-only membership.

Family Membership: Covers the subscriber and eligible dependents to age 26. This may include the subscriber’s spouse and/or eligible dependents.

Allowable Charge Claim amounts are based on the allowable charge for a covered service. Generally, the allowable charge for services by in-network providers will be the contracted amount with BCBSNE. The allowable charge for services by non-contracting providers is the amount we determine for out-of-network. Members are responsible for the charges in excess of the allowable charge for services provided by a non-contracted provider.

Out-of-pocket Limit (includes deductible, coinsurance and copayment amounts for medical services)

The policy has a yearly out-of-pocket limit, which is the total amount of cost-sharing members are required to pay toward the cost of their health care. After their annual out-of-pocket limit is reached, the policy pays covered services at 100% for the rest of the benefit year. In-network and out-of-network deductible and out-of-pocket limits are separate, meaning charges for out-of-network services to not accumulate towards the in-network out-of-pocket maximum, and vice versa. The out-of-pocket limit does not include charges for noncovered services, prescription charges or premium amounts.

Inpatient Hospital Benefits (including long-term acute care)

Benefits are available for (but not limited to):

• Semi-private room; cardiac and intensive care units; treatment rooms and equipment

• Anesthesia • FDA-approved drugs, intravenous solutions and

vaccines administered in the hospital • Physical, occupational and speech therapy • Radiology, pathology and radiation therapy • Respiratory care • Inpatient physical rehabilitation, subject to certain

requirements* • Up to 60 days per benefit year in a skilled nursing

facility when ordered by a physician*

*requires certification

Outpatient Hospital Benefits Benefits for the covered services listed under “Inpatient Hospital Benefits” are also available (subject to certain limitations) when they are received in a hospital outpatient department, emergency room or ambulatory surgical facility. Benefits for outpatient cardiac and pulmonary rehabilitation are available, subject to medical necessity criteria.

BENEFITS AND RESPONSIBILITIESBenefits for Physician’s Services Benefits are available for (but not limited to):

• Allergy serums and injections of allergy extracts • Anesthesia services• Consultation services• Tissue examinations• Physician home and outpatient visits • Radiation therapy and chemotherapy • Radiology, pathology and other diagnostic

services • Surgery and surgical assistance

(for specified procedures)• FDA-approved drugs• Inpatient hospital visits

Primary Care Physician and Specialist Office Services Copays* When a member goes to a network primary care physician or specialist, he or she pays the policy’s designated copay for office visit services. Only covered services and supplies obtained in the physician’s office will be payable under the of fice services copay benefit. For office visits to out-of-network primary care physicians and specialists, benefits for covered services will be subject to the policy’s applicable deductible and coinsurance amounts.

Covered services include:

• Physician office visits and consultations• X-ray, lab and pathology services performed/read

in the physician’s office• Supplies used to treat the patient during the

office visit (excluding home medical equipment)• Drugs administered during an office visit• Hearing and vision exams (non-routine)• Allergy testing and injections

For purposes of this coverage, a “primary care physician“ is a physician who has a majority of his or her practice in the fields of internal or general medicine, obstetrics/gynecology, general pediatrics or family practice. All other types of physicians are considered specialists.

Benefits for Mental Illness and Substance Dependence or ServicesBenefits will be provided for covered outpatient services for the treatment of mental illness and substance dependence and abuse. Covered services include but are not limited to:

• Psychological therapy and/or substance dependence and abuse counseling by approved providers

• Office visits• Specified outpatient programs• Emergency care services

Certain exclusions/limitations may apply.

Benefits for Preventive ServicesBenefits for in-network preventive services will not be subject to cost-sharing requirements, such as copayment, coinsurance or deductible. A listing of these services is available upon request.

Benefits will also be provided for other preventive services, including:

• Specific laboratory/pathology services• Hearing screenings and examinations• Prostate cancer screenings

For more information on preventive services, visit NebraskaBlue.com/PreventiveCare.

*The primary care physician/specialist office services copay benefit is not available under all Armor options. Benefits for all covered services are subject to deductible and coinsurance amounts for policies that do not include the primary care physician/specialist office services copay.


Benefits for Oral SurgeryBenefits are available for (but not limited to) the following covered services:

• Removal of tumors and cysts• Nonsurgical treatment of infections• Treatment of jaw joint dislocation/fracture due

to an accident. Services must occur within 12 months of an injury not related to eating, biting or chewing

• Services, supplies or appliances for dental treatment of natural healthy teeth required as the direct result of an accidental injury. Benefits for such services are limited, however, to covered services provided within 12 months of the date of injury. Benefits are not available for orthodontics or dental implants. Benefits shall not be provided for services when the injury occurs as the result of eating, biting or chewing

• Medically necessary hospitalization and general anesthesia in order for the covered person to safely receive dental care, including covered persons who are under eight years of age

• Diagnostic services and surgery related to temporomandibular jaw joint (TMJ)

Benefits for Organ and Tissue TransplantsBenefits are available for services associated with medically necessary organ and tissue transplants, including (but not limited to) liver; heart; single and double lung; lobar lung; heart-lung; heart valve (heterograft); kidney; kidney-pancreas; pancreas; bone graft; cornea; parathyroid; small intestine; small intestine and liver; small intestine and multiple viscera.

Benefits are also available for bone marrow transplants, including, but not limited to, autologous and allogeneic stem cell transplants.

Transplant procedures require certification by BCBSNE and are subject to medical policy criteria.

Benefits for Home Skilled Nursing Care, Home Health Aide, Hospice Services and Respiratory CareThe following covered services require benefit preauthorization. Limitations and exclusions apply.

• Skilled nursing care: Benefits are available for medically necessary physician-ordered care by a registered or licensed practical nurse for up to eight hours per day.

• Home health aide: When services are related to active medical treatment, benefits include personal services such as bathing, feeding and performing necessary household duties for a homebound patient. (Maximum of 60 days per benefit year)

• Hospice services: Benefits include Medicare-certified hospice services for a terminally ill patient, including home health aide and hospice nursing services, respite care, medical social worker visits, crisis care and bereavement counseling.

• Respiratory care: Benefits are available for respiratory care services in the home, including airway maintenance, chest physiotherapy, delivery of medications, oxygen therapy, obtaining laboratory samples and pulmonary function testing. (Maximum of 60 days per benefit year)

Other Covered Services (Please note: Limitations and exclusions apply.)

• Diabetes outpatient self-management training and patient management from an approved provider

• Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit of 45 sessions per benefit year)

• Rental/initial purchase (whichever costs less) of medically necessary home medical equipment ordered by a doctor; limited benefits are available for the repair, maintenance and adjustment of purchased covered medical equipment

• Services in accordance with the Women’s Health and Cancer Rights Act, which requires that insurance companies that provide medical and surgical benefits for mastectomies also provide benefits for breast reconstruction, prostheses and treatment for physical complications

Refer to the contract for a complete listing.

Exclusions and Limitations This document contains only a partial list of the limitations and exclusions that apply to Armor Health policy coverage. For a complete listing, please refer to the contract.

No benefits are available for the following:

• Services related to a pre-existing condition while the pre-existing waiting period is in effect

• Maternity services including pre and postnatal care and delivery1

• Eyeglasses, contact lenses, eye exercises or visual training

• Blood, plasma, or services by or for blood donors• Artificial insemination; in vitro fertilization; fertility

treat ment, and related testing• Massage therapy and/or services provided by a

massage therapist• Treatment for weight reduction/obesity, including

surgical procedures• Nutrition care, supplies, supplements or other

nutritional substances, including Neocate, Vivonex and other over-the-counter infant formulas and supplements

• Radial keratotomy or any other procedures/alterations of the refractive character of the cornea to correct myopia, hyperopia and/or astigmatism

• Services we consider to be investigative, not medically necessary, experimental, cosmetic or obsolete

• Services, drugs, medical supplies, devices or equipment that are not cost effective compared to established alternatives or that are provided for the convenience or personal use of the patient

• Services provided before the coverage effective date or after termination

• Services for illness or injury sustained while performing military service

• Services for injury/illness arising out of or in the course of employment for an employer or individual covered by Worker’s Compensation.

• Charges for services which are not within the provider’s scope of practice

• Charges in excess of our contracted amount• Charges made separately for services, supplies

and materials we consider to be included within the total charge payable

• Routine eye exams• Pediatric dental • Pediatric vision• Inpatient treatment for mental illness or

substance abuse disorders

Certification RequirementsThe purpose of certification is to determine whether a service or admission meets the medical necessity criteria of the policy.

All inpatient hospital admissions must be certified by BCBSNE. This enables us to coordinate discharge planning, case management and disease management services with the patient’s providers. If the patient is hospitalized in a contracting (in-network) hospital in Nebraska, notification will be provided by the hospital.

If the patient is hospitalized in a non-contract (out-of-network) hospital in Nebraska or is admitted to an inpatient facility in another state, BCBSNE must be notified by the patient or their provider.

Certification is also required for the following care, regardless of where the care is received, in or out of network:

• Inpatient physical rehabilitation • Long-term acute care • Skilled nursing facility care • Skilled nursing in the home• Organ and tissue transplants• Certain prescription drugs

This is not a complete list. Please refer to the contract for additional information.

The covered person is responsible for making sure that certification occurs; however a hospital or provider may initiate the certification. When possible, certification should be completed prior to receiving the services. Benefits for services that are not certified or that are not medically necessary will be denied, the member will be responsible for the charges.

For certification of benefits for an inpatient admission, call 800-247-1103 or 402-390-1870.


Affordable Care Act (ACA) Plan Comparison

In accordance with Nebraska Department of Insurance regulations, the following chart compares the benefits available under the non-ACA Armor Health plan versus a typical ACA plan available to Nebraska consumers.

Allowable Charge: An amount we use to calculate our payment of covered services. This amount will be based on either the contracted amount for in-network providers or the out-of-network allowance.

Benefit Year: The 12-month period of coverage beginning on your policy’s effective date.

Coinsurance: The percentage of the bill you pay after your deductible has been met.

Copayment (copay): A fixed amount you pay when you get a covered health service. For example, a doctor’s office visit.

Deductible: The amount you pay for health services each benefit year before your insurance begins to pay.

Drug Tiers:

Preferred Generic Drugs: Commonly prescribed generic drugs

Non-preferred Generic Drugs: Higher-priced generic drugs that cost a little more than preferred generic

Preferred Brand-name Drugs: Brand name drugs that do not have a generic equivalent.

Non-preferred Brand-name Drugs: Higher-priced brand-name drugs. Often have a generic equivalent.

Specialty Drugs: High-cost drugs used to treat complex conditions like cancer.

Embedded: For family coverage, family members may combine their covered expenses to satisfy the required family deductible or coinsurance maximum. No one family member contributes more than the individual deductible or coinsurance maximum amount to satisfy the family deductible or coinsurance maximum.

Emergency Care Services: Any covered services received in a hospital emergency room setting.

Hospice: A program of care provided for persons diagnosed as terminally ill, and their families.

Inpatient Care: Care you receive that requires admission to a hospital.

In-network Providers: A provider contracted by your insurance company to accept an agreed-upon payment for covered services.

Lifetime Maximum: The maximum dollar amount the policy will pay for covered services during a covered person’s lifetime.

Non-covered Services: Services that are not payable under the contract.

Out-of-network Provider: A term for providers that aren’t contracting with your insurance policy. (Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.)

Out-of-pocket Maximum: Your expenses for medical care that aren’t reimbursed by your policy, including deductibles, coinsurance, and copayments for covered services.

GLOSSARY OF TERMS

Outpatient Care: Care you receive at a hospital or health care facility without being admitted.

Pre-existing Condition: Any condition for which the member received medical advice or treatment for within 12 months prior to enrollment.

Preferred Provider Organization (PPO): A health benefit program that offers the highest level of benefits to members when they obtain services from any physician or hospital designated as a PPO provider. Substantial benefits still are provided when the member obtains care from another provider of choice. No primary care physician gatekeeper/referral is required for access to PPO providers. The PPO provider network includes, at a minimum, hospitals and physicians and may include, at a minimum, hospitals, physicians and other health care providers.

Premium: The amount you are charged each month for your health insurance policy.

Preventive Services: Routine health care that includes screenings and check-ups to prevent illness, disease, or other health problems.

Primary Care Physician (PCP): A physician who has a majority of his or her practice in the fields of internal or general medicine, obstetrics/gynecology, general pediatrics or family practice.

1https://www.bolgerapps.com/medica_sb7/usum/output_cache/1111-155636-2021010611385839580-final.pdf

Armor Health (Option 1)

ACA Preferred Tier Gold Plan1 (For comparison purposes only)

Lifetime Maximum $1,000,000 No lifetime maximum under ACA

Pre-existing Conditions Covered after a 12-month waiting period Rates will vary based on health condition Covered

Renewability Renewed each month when premiums are paid for a period of 364 days and

will be guaranteed renewable for one (1) day or two (2) days during a Leap Year

Guaranteed Renewable

Primary Care Office Services $30 Office Services Copay $30 Office Visit Copay

Pharmacy Benefits

Preferred Generic Drugs $0 Copay $5 Copay

Specialty Drugs Member Pays 100% $500 Copay

Pregnancy and Maternity Not Covered Deductible and 30% Coinsurance

Mental Illness and Substance Abuse Services

Inpatient Not Covered Deductible and 30% Coinsurance

Outpatient Deductible and 20% Coinsurance $30 Office Visit Copay

Preventive Care Services

ACA-required preventive services (may be subject to limits that include, but are not limited to, age, gender, and frequency)

Plan Pays 100% Plan Pays 100%

ACA required covered preventive services (outside of limits) Plan Pays 100% See Plan Details

Other covered preventive services not required by ACA

Laboratory tests as specified by Us, including urinalysis and complete blood count; general health panel; comprehensive metabolic panel; prostate cancer screening (PSA) and hearing exams

Plan Pays 100% See Plan Details

All other laboratory tests; radiology, cardiac stress tests; EKG; pulmonary function and other screenings and services

Same as an Illness See Plan Details

Emergency Care

Urgent Care Facility Services $75 Copay first 3 visits then Deductible and Coinsurance $30 Office Visit Copay

Emergency Care Services Deductible and 50% Coinsurance Deductible and 30% Coinsurance

Inpatient Hospital Deductible and 20% Coinsurance Deductible and 30% Coinsurance

Ambulance Services Deductible and 20% Coinsurance Deductible and 30% Coinsurance

Pediatric Vision Not Covered Deductible and 30% Coinsurance

Pediatric Dental Not Covered Not Covered

Network ProvidersStatewide Directory

NebraskaBlue.com/Find-a-Doctor Nebraska adequacy laws apply

This plan has to comply with the Nebraska network adequacy laws

This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your policy carefully to make sure you are aware of any exclusions or limitations regarding coverage of pre-existing conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). Your policy might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage.

Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross and Blue Shield Association. 92-196 (08-18-21)

Call your insurance broker or a member of our sales team at 888-926-1203 to apply.

NebraskaBlue.com/ArmorHealth

Apply for an Armor Health policy!

Download - ARMOR HEALTH - Health Insurance, Medicare & Dental Insurance

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