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Medicare Advantage · HMO
Blue Cross and Blue Shield of Nebraska
Plan year 2026

Blue Cross and Blue Shield of Nebraska MA Core H3170-003 (HMO)

Monthly premium
$0
+ your Part B premium
Max out-of-pocket
$4,100
in-network annual cap
Primary care
$0
per visit copay
Specialist
$35
per visit

Your costs at a glanceIn-network, for the 2026 plan year

Rx deductible
$400
Inpatient hospital
Days 1-4: $400/day, Days 5-90: $0/day
no limit on covered hospital days
Inpatient mental health
Days 1-4: $420/day, Days 5-90: $0/day
Outpatient surgery
$350
Emergency room
$135
Urgent care
$55

What's included, and what it's actually worth5 benefits included. Tap any card for the detail

Dental

$1,200/yr allowance
Annual max$1,200/yr allowance
This is a supplemental benefit with plan-specific limits. See plan documents for details.

Hearing

$395–$1,595copay per hearing aid
Details$395–$1,595 copay per hearing aid
This is a supplemental benefit with plan-specific limits. See plan documents for details.

Vision

$300/yr eyewear allowance ($35 exam copay)
Eyewear allowance$300/yr eyewear allowance
Routine eye exam$35 copay
This is a supplemental benefit with plan-specific limits. See plan documents for details.

OTC allowance

$50/quarter OTC allowance
Prepaid card$50/quarter OTC allowance
See more details about this plan
Doctor Visits: PCP$0 copay
In-network$0 copay per visit
Doctor Visits: Specialist$35 copay
In-network$35 copay per visit
Inpatient Hospital$400/day, days 1–4
In-networkDays 1-4: $400/day, Days 5-90: $0/day
Benefit limitNone — additional covered days are unlimited
Outpatient Surgery$350 copay
In-network$350 copay per procedure
Mental HealthDays 1-4: $420/day, Days 5-90: $0/day
Inpatient psychiatricDays 1-4: $420/day, Days 5-90: $0/day
MealsMeal benefit

Your coverageCheck your coverageFrom the doctors and prescriptions you added

Your plan's drug tiers30-day retail · after any applicable deductible

Tier 1
$0
Preferred Generic
Tier 2
$14
Generic
Tier 3
$47
Preferred Brand· after deductible
Tier 4
$100
Non-Pref Brand· after deductible
Tier 5
28%
Specialty· after deductible

Our take

Where this plan shines

This plan has a $0 monthly premium.
This plan’s out-of-pocket maximum is below the national median.
See your primary doctor for $0.

Things to know before you enroll

Network restriction — you’ll need to use in-network providers except in emergencies.
Limited coverage while traveling outside the plan’s service area.
Questions? Talk to a licensed agent at1-866-764-3312 (TTY: 711)

Plan documents

Summary of Benefits (PDF)
Download the plan's official Summary of Benefits document
Check Your Doctors
See if your doctors accept this plan
Documentos en español
Llame al (844)899-6060 (TTY: 711) para solicitar documentos en español

Helpful next steps

The Pocket Protector · NPN 21126942 · 1-866-764-3312 (TTY: 711) · thepocketprotector.com

Plan benefits, premiums, and copays may vary by county and plan. You must continue to pay your Medicare Part B premium. Benefits and costs may vary by service area. Contact the plan or CMS for complete details.

We do not offer every plan available in your area. Currently we represent a limited number of organizations which offer a limited number of products in your area. Please contact Medicare.gov, 1-800-MEDICARE (TTY: 1-877-486-2048), or your local State Health Insurance Program (SHIP) to get information on all of your options.

Members may receive a monthly or quarterly allowance in the form of a benefits prepaid card to pay for a wide range of plan-approved items. Unused amounts will expire at the end of the month or quarter.

Out-of-network/non-contracted providers are under no obligation to treat plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you to contact the plan.

Dental, hearing, vision, and other supplemental benefits may have limitations and restrictions. These benefits vary by plan. Please refer to the plan's Evidence of Coverage for details.

The plan formulary, pharmacy network, and/or copays may change at any time. You will receive notice when necessary.

Benefits shown are based on CMS public plan data. Actual benefits vary by county. Not all plans available in all areas. Speak with a licensed agent before enrolling.

  1. The Pocket Protector represents Medicare Advantage HMO, PPO, and PFFS organizations and stand-alone PDP prescription drug plans that have a Medicare contract. Enrollment depends on the plan's contract renewal.
  2. The Pocket Protector is not connected with or endorsed by the United States government or the federal Medicare program.

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Blue Cross and Blue Shield of Nebraska MA Core (HMO) - Blue Cross and Blue Shield of Nebraska | The Pocket Protector