medicare supplement outline of coverage blue cross …...available. only applicants' first...

Rates Valid: April 1, 2020 through March 31, 2021For Plans Effective: January 1, 2020

Benefit Plans: A, B, C, F, G, L and N

MEDICARE SUPPLEMENT OUTLINE OF COVERAGEBlue Cross and Blue Shield of Nebraska

Table of Contents

BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS 3

MONTHLY PREMIUMS

AREA 1 (ZIP Codes 680-681) 4




IMPORTANT INFORMATION 20

PLAN DESCRIPTIONS

PLAN A 22

PLAN B 24

PLAN G 26

PLAN L 28

PLAN N 30

PLAN C 32

PLAN F 34

RATE ZONES | Based on ZIP Code

AREA 4 (ZIP Codes 690-693)




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1 Plans F and G also have a high deductible option which require first paying a plan deductible of $2,340 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductibled toward meeting the plan deductible.

2 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.

3 Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in inpatient admission.

BENEFIT CHART OF MEDICARE SUPPLEMENT PLANSFor Plans Effective: January 1, 2020 through December 31, 2020This chart shows the benefits included in each of the standard Medicare supplement plans. Some plans may not be available. Only applicants' first eligible for Medicare before 2020 may purchase Plans C, F and high deductible F.

Note: a 4 means 100% of the benefit is paid

Plan A Plan B Plan D Plan G1 Plan K Plan L Plan M Plan N Plan C Plan F1

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)

4 4 4 4 4 4 4 4 4 4

Medicare Part B coinsurance or copayment 4 4 4 4 50% 75% 443

copays apply 4 4

Blood (first 3 pints) 4 4 4 4 50% 75% 4 4 4 4

Part A hospice care coinsurance or copayment 4 4 4 4 50% 75% 4 4 4 4

Skilled nursing facility care coinsurance 4 4 50% 75% 4 4 4 4

Medicare Part A deductible 4 4 4 50% 75% 50% 4 4 4

Medicare Part B deductible 4 4

Medicare Part B excess charges 4 4

Foreign travel emergency (up to plan limits) 4 4 4 4 4 4

Out-of-pocket limit in [2019]2 [$5,560]2 [$2,940]2

Medicare first eligible before 2020 only

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MONTHLY PREMIUMS | PREFERRED – Non-Tobacco User AREA 1 (ZIP Codes 680-681)

AgePlan A Plan B Plan G Plan L Plan N Plan C Plan F

Male Female Male Female Male Female Male Female Male Female Male Female Male Female65 142.00 123.48 178.09 154.86 128.90 112.09 98.69 85.81 92.48 80.42 165.28 143.73 183.77 159.8066 142.00 123.48 178.09 154.86 128.90 112.09 98.69 85.81 92.48 80.42 165.28 143.73 183.77 159.8067 142.00 123.48 178.09 154.86 128.90 112.09 98.69 85.81 92.48 80.42 165.28 143.73 183.77 159.8068 149.81 130.27 187.89 163.38 135.99 118.26 104.12 90.54 97.57 84.84 174.37 151.63 193.89 168.6069 157.63 137.07 197.69 171.90 143.08 124.42 109.54 95.26 102.65 89.26 183.46 159.53 203.99 177.3870 165.44 143.86 207.48 180.41 150.16 130.58 114.96 99.97 107.74 93.69 192.55 167.44 214.10 186.1771 172.54 150.03 216.38 188.16 156.61 136.18 119.90 104.26 112.36 97.71 200.81 174.62 223.29 194.1672 179.64 156.21 225.28 195.90 163.06 141.79 124.84 108.56 116.98 101.73 209.08 181.81 232.47 202.1573 186.74 162.38 234.19 203.64 169.50 147.39 129.77 112.84 121.61 105.74 217.34 188.99 241.66 210.1474 193.84 168.56 243.09 211.38 175.95 153.00 134.71 117.14 126.24 109.77 225.61 196.18 250.85 218.1375 200.94 174.73 252.01 219.14 182.39 158.60 139.64 121.43 130.86 113.79 233.87 203.37 260.04 226.1276 207.33 180.29 260.02 226.10 188.19 163.65 144.08 125.29 135.02 117.41 241.31 209.84 268.31 233.3177 213.73 185.85 268.03 233.07 194.00 168.69 148.53 129.15 139.18 121.03 248.75 216.31 276.58 240.5078 220.11 191.40 276.04 240.04 199.80 173.74 152.96 133.01 143.35 124.65 256.19 222.78 284.85 247.6979 226.50 196.95 284.06 247.01 205.60 178.78 157.41 136.88 147.51 128.27 263.62 229.24 293.12 254.8980 232.89 202.51 292.07 253.97 211.40 183.83 161.84 140.73 151.67 131.89 271.06 235.70 301.39 262.0881 237.86 206.83 298.31 259.40 215.91 187.75 165.30 143.74 154.91 134.70 276.85 240.74 307.82 267.6782 242.83 211.16 304.53 264.81 220.42 191.67 168.75 146.74 158.14 137.51 282.63 245.77 314.26 273.2783 247.80 215.48 310.77 270.24 224.93 195.60 172.20 149.74 161.37 140.32 288.42 250.80 320.68 278.8584 252.77 219.80 317.01 275.66 229.45 199.52 175.66 152.75 164.62 143.15 294.20 255.83 327.12 284.4585 257.74 224.12 323.24 281.08 233.96 203.44 179.12 155.75 167.85 145.96 299.99 260.86 333.55 290.0486 259.87 225.98 325.91 283.40 235.89 205.12 180.59 157.04 169.24 147.16 302.47 263.02 336.30 292.4487 262.00 227.83 328.58 285.72 237.83 206.81 182.08 158.33 170.63 148.37 304.95 265.17 339.07 294.8488 264.13 229.68 331.26 288.05 239.75 208.48 183.55 159.61 172.01 149.58 307.42 267.32 341.82 297.2489 266.26 231.53 333.92 290.37 241.68 210.16 185.04 160.90 173.40 150.78 309.90 269.48 344.57 299.63

90+ 268.39 233.39 336.60 292.70 243.62 211.84 186.51 162.18 174.79 151.99 312.38 271.63 347.34 302.03Only available to those Medicare eligible prior to January 1,2020

Rates valid through March 31, 2021. Premium is based on your gender and age as of April 1, 2020. Premium payment may be made monthly.

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MONTHLY PREMIUMS | PREFERRED – Non-Tobacco UserAREA 1 (ZIP Codes 680-681) – Household Discount Applied*



90+ 228.13 198.38 286.11 248.80 207.08 180.06 158.53 137.85 148.57 129.19 265.52 230.89 295.24 256.73Only available to those Medicare eligible prior to January 1,2020Rates valid through March 31, 2021. Premium is based on your gender and age

as of April 1, 2020. Premium payment may be made monthly. *See page 20 for information regarding household premium discount.

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MONTHLY PREMIUMS | STANDARD – Tobacco UserAREA 1 (ZIP Codes 680-681)





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MONTHLY PREMIUMS | STANDARD – Tobacco UserAREA 1 (ZIP Codes 680-681) – Household Discount Applied*





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MONTHLY PREMIUMS | PREFERRED – Non-Tobacco UserAREA 2 (ZIP Codes 683-685)





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IMPORTANT INFORMATION

Premium InformationWe, Blue Cross and Blue Shield of Nebraska, can only raise your premium if we raise the premium for all policies like yours in this state. Your premium may change each year as you age, and that change will be made on the annual renewal date, and the rate will be calculated using your attained age as of the renewal date. If you change the geographic area in which you reside, it may result in a premium change.

Your contract is guaranteed renewable. It cannot be canceled because of the number of claims you file or the amount of benefits you collect. It should be expected that your premiums will increase whenever Medicare deductibles or coinsurance provisions change, or when higher medical costs require a greater charge.

Household Premium DiscountYou are eligible for a household premium discount if you currently have a person residing in your home (but no more than three people, age 60 or older), who is: a) your legal spouse; or b) a person at least 18 years of age with whom you have resided continuously for the last 12 months. The discount on the premium will be 15 percent. The policy's household premium discount will be removed if the other adult or spouse no longer resides with you (other than in the case of his or her death).

Disclosures Use this outline to compare benefits and premiums among policies.

Read Your Policy Very Carefully This is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and Blue Cross and Blue Shield of Nebraska.

Right To Return Policy If you find that you are not satisfied with your policy, you may return it to:

Blue Cross and Blue Shield of Nebraska P.O. Box 3248 Omaha, NE 68180-0001

If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.

Policy Replacement If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.

Notice These policies may not fully cover all of your medical costs.

Neither Blue Cross and Blue Shield of Nebraska nor its agents are connected with Medicare.

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult the “Medicare and You” handbook for more details.

Complete Answers Are Very Important When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The Company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

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NOTES

22

PLAN A | Medicare (Part A) Hospital Services – Per Benefit Period* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you

have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES MEDICARE PAYS PLAN A PAYS YOU PAYHOSPITALIZATION*Semiprivate room and board, general nursing, miscellaneous services and supplies.First 60 days All but $1,408 $0 $1,408 (Part A deductible)

61st through 90th day All but $352 a day $352 a day $091st day and after:

• While using 60 lifetime reserve days• Once lifetime reserve days are used:

- 365 additional days- Beyond the additional 365 days

All but $704 a day

$0$0

$704 a day

100% of Medicare-eligible expenses$0

$0

$0 **All costs

SKILLED NURSING FACILITY CARE*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital.First 20 days All approved amounts $0 $0

21st through 100th day All but $176 a day $0 Up to $176 a day

101st day and after $0 $0 All costs

BLOOD

First 3 pints $0 3 pints $0

Additional amounts 100% $0 $0HOSPICE CAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness.

All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance $0

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

23

PLAN A | Medicare (Part B) Medical Services – Per Calendar Year* Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with an asterisk),

your Part B deductible will have been met for the calendar year.

SERVICES MEDICARE PAYS PLAN A PAYS YOU PAYMEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENTsuch as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speechtherapy, diagnostic tests and durable medical equipment.First $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)

Remainder of Medicare-approved amounts Generally 80% Generally 20% $0Part B excess charges (above Medicare-approved amounts)

$0 $0 All costs

BLOOD

First 3 pints $0 All costs $0

Next $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)

Remainder of Medicare-approved amounts 80% 20% $0

CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES

100% $0 $0PARTS A AND BHOME HEALTH CARE – MEDICARE-APPROVED SERVICESMedically necessary skilled care services and medical supplies

100% $0 $0

Durable medical equipment: First $198 of Medicare-approved amounts*

$0 $0 $198 (Part B deductible)


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PLAN B | Medicare (Part A) Hospital Services – Per Benefit Period* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you


SERVICES MEDICARE PAYS PLAN B PAYS YOU PAYHOSPITALIZATION*Semiprivate room and board, general nursing, miscellaneous services and supplies.First 60 days All but $1,408 $1,408 (Part A deductible) $0




All but $704 a day

$0$0

$704 a day


$0

$0 **All costs


21st through 100th day All but $176 a day $0 Up to $176 a day


BLOOD






25

PLAN B | Medicare (Part B) Medical Services – Per Calendar Year* Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with an asterisk),


SERVICES MEDICARE PAYS PLAN B PAYS YOU PAYMEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENTsuch as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speechtherapy, diagnostic tests and durable medical equipment.First $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)


$0 $0 All costs

BLOOD





100% $0 $0PARTS A AND BHOME HEALTH CARE – MEDICARE-APPROVED SERVICESMedically necessary skilled care services andmedical supplies

100% $0 $0




26

PLAN G | Medicare (Part A) Hospital Services – Per Benefit Period* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you


SERVICES MEDICARE PAYS PLAN G PAYS YOU PAYHOSPITALIZATION*Semiprivate room and board, general nursing, miscellaneous services and supplies.First 60 days All but $1,408 $1,408 (Part A deductible) $0




All but $704 a day

$0$0

$704 a day


$0

$0 **All costs


21st through 100th day All but $176 a day Up to $176 a day $0


BLOOD




Medicarecopayment/coinsurance

$0


27

PLAN G | Medicare (Part B) Medical Services – Per Calendar Year* Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with an asterisk),


SERVICES MEDICARE PAYS PLAN G PAYS YOU PAYMEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENTsuch as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speechtherapy, diagnostic tests and durable medical equipment.First $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)


$0 100% $0

BLOOD






100% $0 $0




Other Benefits – Not Covered By MedicareSERVICES MEDICARE PAYS PLAN G PAYS YOU PAYFOREIGN TRAVEL – NOT COVERED BY MEDICAREMedically necessary emergency care services beginning during the first 60 days of each trip outside the U.S.A.First $250 each calendar year $0 $0 $250

Remainder of charges $080% to a lifetime maximumbenefit of $50,000

20% and amounts over the$50,000 lifetime maximum

28

PLAN N | Medicare (Part A) Hospital Services – Per Benefit Period* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you


SERVICES MEDICARE PAYS PLAN N PAYS YOU PAYHOSPITALIZATION*Semiprivate room and board, general nursing, miscellaneous services and supplies.First 60 days All but $1,408 $1,408 (Part A deductible) $0




All but $704 a day $0 $0

$704 a day 100% of Medicare-eligble expenses $0

$0 $0** All costs




BLOOD



All but very limited copayment/coinsurance for outpatient drugs andinpatient respite care



29**The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

PLAN N | Medicare (Part B) Medical Services – Per Calendar Year* Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with an asterisk),


SERVICES MEDICARE PAYS PLAN N PAYS YOU PAYMEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests and durable medical equipment.First $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)

Remainder of Medicare-approved amounts Generally 80%

Balance, other than $20 per office visit and $50 per emergency room visit copayment amount**

Up to $20 per office visit and up to $50 per emergency room visit**

Part B excess charges (above Medicare-approved amounts)

$0 $0 All costs

BLOOD






100% $0 $0




Other Benefits – Not Covered By MedicareSERVICES MEDICARE PAYS PLAN G PAYS YOU PAYFOREIGN TRAVEL – NOT COVERED BY MEDICAREMedically necessary emergency care services beginning during the first 60 days of each trip outside the U.S.A.First $250 each calendar year $0 $0 $250

Remainder of charges $080% to a lifetime maximum benefit of $50,000


30

PLAN L

Hospital Services – Per Benefit Period

* You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2,940 each calendar year. The amounts that count toward your annual limit are noted with diamonds (u) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

SERVICES MEDICARE PAYS PLAN L PAYS YOU PAYHOSPITALIZATION **Semiprivate room and board, general nursing, miscellaneous services and supplies.

First 60 days All but $1,408 $1,056 (75% of Part A deductible)$352 (25% of Part A deductible) u




All but $704 a day

$0$0

$704 a day


$0

$0 ***All costs

SKILLED NURSING FACILITY CARE **You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital.First 20 days All approved amounts $0 $0

21st through 100th day All but $176 a day Up to $132 a day Up to $44 a day u


BLOOD

First 3 pints $0 75% 25% u



75% of copayment/coinsurance25% of copayment/coinsurance u

*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

Medicare (Part A)

31

PLAN L | Medicare (Part B) Medical Services – Per Calendar Year

SERVICES MEDICARE PAYS PLAN L PAYS YOU PAYMEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENTsuch as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speechtherapy, diagnostic tests and durable medical equipment.First $198 of Medicare-approved amounts **** $0 $0 $198 (Part B deductible) **** u

Preventive Benefits for Medicare-covered servicesGenerally 75% or more of Medicare-approved amounts

Remainder of Medicare-approved amounts

All costs above Medicare-approved amounts

Remainder of Medicare-approved amounts Generally 80% Generally 15% Generally 5% u

Part B excess charges (above Medicare-approved amounts)

$0 $0 All costs (and they do notcount toward annual out-of-pocket limit of $2,940) *

BLOOD

First 3 pints $0 75% 25% u

Next $198 of Medicare-approved amounts **** $0 $0 $198 (Part B deductible) u

Remainder of Medicare-approved amounts Generally 80% Generally 15% Generally 5% u


100% $0 $0PARTS A AND B HOME HEALTH CARE – MEDICARE-APPROVED SERVICESMedically necessary skilled care services andmedical supplies

100% $0 $0

Durable medical equipment: First $198 of Medicare-approved amounts *****

$0 $0 $198 (Part B deductible) u

Remainder of Medicare-approved amounts 80% 15% 5% u

* This plan limits your annual out-of-pocket payment for Medicare-approved amounts to $2,940 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “excess charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

***** Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

**** Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

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PLAN C | Medicare (Part A) Hospital Services – Per Benefit Period* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you


SERVICES MEDICARE PAYS PLAN C PAYS YOU PAYHOSPITALIZATION*Semiprivate room and board, general nursing, miscellaneous services and supplies.First 60 days All but $1,408 $1,408 (Part A deductible) $0




All but $704 a day

$0$0

$704 a day


$0

$0 **All costs




BLOOD






Only available for individuals who were Medicare eligible before Jan. 1, 2020.

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PLAN C | Medicare (Part B) Medical Services – Per Calendar Year* Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with an asterisk),


SERVICES MEDICARE PAYS PLAN C PAYS YOU PAYMEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENTsuch as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speechtherapy, diagnostic tests and durable medical equipment.First $198 of Medicare-approved amounts* $0 $198 (Part B deductible) $0


$0 $0 All costs

BLOOD


Next $198 of Medicare-approved amounts* $0 $198 (Part B deductible) $0




100% $0 $0


$0 $198 (Part B deductible) $0


Other Benefits – Not Covered By MedicareSERVICES MEDICARE PAYS PLAN C PAYS YOU PAYFOREIGN TRAVEL – NOT COVERED BY MEDICAREMedically necessary emergency care services beginning during the first 60 days of each trip outside the U.S.A.First $250 each calendar year $0 $0 $250




34

PLAN F | Medicare (Part A) Hospital Services – Per Benefit Period* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you


SERVICES MEDICARE PAYS PLAN F PAYS YOU PAYHOSPITALIZATION*Semiprivate room and board, general nursing, miscellaneous services and supplies.First 60 days All but $1,408 $1,408 (Part A deductible) $0




All but $704 a day

$0$0

$704 a day


$0

$0 **All costs




BLOOD




Medicarecopayment/coinsurance

$0



35

PLAN F | Medicare (Part B) Medical Services – Per Calendar Year* Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with an asterisk),


SERVICES MEDICARE PAYS PLAN F PAYS YOU PAYMEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENTsuch as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speechtherapy, diagnostic tests and durable medical equipment.First $198 of Medicare-approved amounts* $0 $198 (Part B deductible) $0


$0 100% $0

BLOOD


Next $198 of Medicare-approved amounts* $0 $198 (Part B deductible) $0




100% $0 $0


$0 $198 (Part B deductible) $0


Other Benefits – Not Covered By MedicareSERVICES MEDICARE PAYS PLAN F PAYS YOU PAYFOREIGN TRAVEL – NOT COVERED BY MEDICAREMedically necessary emergency care services beginning during the first 60 days of each trip outside the U.S.A.First $250 each calendar year $0 $0 $250




P.O. Box 3248 • Omaha, NE 68180-0001Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross and Blue Shield Association.

9175 (01-30-20)

medicare supplement outline of coverage blue cross …...available. only applicants' first...

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