Summary of Benefits and Coverage - What this Plan Covers & What it Costs

Sep 15, 2026

Plan overview detailing coverage and member costs for an individual/family PPO. Defines key financial terms including overall deductible amounts for in-network and out-of-network care, the out-of-pocket maximum, and which expenses do not count toward those limits. Explains that the plan pays for covered services after deductible and describes how provider networks affect payment levels. Includes common medical event examples and notes about referrals, annual limits, and services not covered, with guidance to consult the policy for final terms.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages17

Reading Time43 min

AccessFree to download

Important Questions

Deductibles and out-of-pocket limits

Annual limits and network of providers

Referrals and excluded services

Common Medical Event cost examples

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: PPO | | This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at [https://www.nebraskablue.com](https://www.nebraskablue.com or by calling 1-888-592-8961)[ or by calling 1-888-592-8961](https://www.nebraskablue.com or by calling 1-888-592-8961). | | --- | --- | | Important Questions Answers Why this Matters: | | | | --- | --- | --- | | What is the overall deductible? | In-network: $350 individual
Out-of-network: $1,000 individual
Does not apply to most preventive care or prescription drugs. Copayments and coinsurance don't count toward the deductible. | You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st) . See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. | | Are there other deductibles for specific services? | No. | You don't have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. | | Is there an out-of-pocket limit on my expenses? | Yes.
In-network: $2,850 individual / $6,050 family
Out-of-network: $5,000 individual /$11,000 family | The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. | | What is not included in the out-of-pocketlimit? | None of the following are included: penalties, premiums, balance-billed charges, and services this plan doesn't cover. | Even though you pay these expenses, they do not count toward the out-of-pocket limit. | Questions: Call 1-888-592-8961 or visit us at [www.nebraskablue.com](www.nebraskablue.com) If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at [http://www.cms.gov/CCIIO/Resources/Files/Downloads/uniform-glossary-final.pdf](http://www.cms.gov/CCIIO/Resources/Files/Downloads/uniform-glossary-final.pdf or call 1-888-592-8961)[ ](http://www.cms.gov/CCIIO/Resources/Files/Downloads/uniform-glossary-final.pdf or call 1-888-592-8961)[or call 1-888-592-8961](http://www.cms.gov/CCIIO/Resources/Files/Downloads/uniform-glossary-final.pdf or call 1-888-592-8961) to request a copy. This document contains only a partial description of the benefits, limitations, exclusions and other provisions of this health care plan. It is not a policy. It is a general overview only. It does not provide all the details of this coverage, including benefits, exclusions and policy limitations. In the event there are discrepancies between this document and the policy, the terms and conditions of the policy will govern. OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 23, 2013 (corrected) . Important Questions Answers Why this Matters: | Is there an overall annual limit on what the plan pays? | No. | The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. | | --- | --- | --- | | Does this plan use a network of providers? | Yes. For a list of in-network providers, see www.nebr[askablue.com](askablue.com) or call 1-888-592-8961 | If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term
in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. | | Do I need a referral to see a specialist? | No. You don’t

FAQs

What is the overall deductible for this PPO plan?

The in-network deductible is $350 for an individual, and the out-of-network deductible is $1,000 for an individual. Most preventive care and prescription drugs are not subject to the deductible.

Is there an out-of-pocket limit, and what expenses do not count toward it?

Yes. The in-network out-of-pocket limit is $2,850 for an individual / $6,050 for a family, and the out-of-network out-of-pocket limit is $5,000 for an individual / $11,000 for a family. Penalties, premiums, balance-billed charges, and non-covered services do not count toward the limit.

Does the plan require a referral to see a specialist, and does it have annual limits?

No referral is needed to see a specialist. There is no overall annual limit on what the plan pays, with specific limits potentially described in the chart for covered services.

Sep 15, 2026

Upload by Taylor Morgan