Benefits Health Insurance
Group #101498
Network BLUE Network
1-888-592-8961
PHARMACY NETWORK
Network C
DRUG LIST
PDL 20 (Formerly “BCBSNE Standard Formulary“)
Compare HRA and HSA
D/C = Deductible/Coinsurance
Associate Plus means Associate + Child(ren), Associate + Spouse or Associate + Family
HSA | HRA | |||
Benefit Summary | In-Network | Out-of-Network | In-Network | Out-of-Network |
Deductible/Coinsurance | Aggregate | Aggregate | ||
Associate | $1,650 | $3,300 | $2,000 | $4,000 |
Associate Plus | $3,300 | $6,600 | $4,000 | $8,000 |
Coinsurance | 25% | 40% | 30% | 50% |
Out-of-Pocket Maximum includes Deductible, Coinsurance, and Copays | ||||
Associate | $3,300 | $6,600 | $4,500 | $9,000 |
Associate Plus | $6,600 | $13,200 | $9,000 | $18,000 |
WoodmenLife HSA or HRA Contributions For associates not enrolled for the entire year, WoodmenLife's contribution will be prorated based on the coverage start date. | ||||
Associate | $500 | $1,000 | ||
Associate Plus | $1,000 | $2,000 | ||
Office Visit | ||||
Primary Care | D/C | D/C | $30 Copay | D/C |
Specialist | D/C | D/C | D/C | D/C |
Other Office Visit Services | D/C | D/C | Included in Copay | D/C |
Preventive Care | 100% | D/C | 100% | D/C |
Virtual Doctor | D/C | D/C | $15 Fee | D/C |
Urgent and Emergency Care | ||||
Physician | D/C | D/C | $55 Copay | D/C |
Other Urgent Care Services | D/C | D/C | Included in Copay | D/C |
Emergency Care | D/C | Same as In-Network | $175 Copay + D/C | Same as In-Network |
Prescription Drug Retail 30-day supply | ||||
Generic | D/C | In-Network + 25% | $15 Copay | In-Network + 25% |
Formulary | D/C | In-Network + 25% | 30%, $37.50 min to $150 max | In-Network + 25% |
Non-Formulary | D/C | In-Network + 25% | 30%, $62.50 min to $250 max | In-Network + 25% |
Specialty | D/C | Not covered | 30%, $75 min to $300 max | Not covered |
Prescription Drug Retail 90-day supply | ||||
Generic | D/C | Not covered | $37.50 Copay | Not covered |
Formulary | D/C | Not covered | 30%, $93.75 min to $375 max | Not covered |
Non-Formulary | D/C | Not covered | 30%, $156.25 min to $625 max | Not covered |
Tools
Find a Doctor
Rx Benefits
Cost Estimator
Telehealth
Go Mobile
Check out more details of each account.
Pre-Tax Premiums
Total health insurance cost, paid by you and WoodmenLife, is based on actual claims over the prior two years, projected claims, administrative expenses for the upcoming year, the plan and level of coverage you select, and your salary/earnings as of Sept. 30.
Benefits of an HSA
To help understand the benefits of a Health Savings Account, click here.