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Basic Option

Stay in-network for care. Basic Option gives you access to our Preferred provider network that includes 96% of hospitals and 95% of doctors in the U.S.

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Basic Option Benefits

See costs for typical services when you use Preferred providers.

Basic Option
Preventive Care Nothing for covered preventive screenings, immunizations and services
Physician Care

$30 copay for primary care1
$40 copay for specialists1

Mental Health Visits $30 copay
Virtual doctor visits by Teladoc®

$0 for first 2 visits
$15 copay all additional visits

Urgent Care Center $35 copay
Prescription Drugs Preferred Retail Pharmacy^:

Tier 1 (Generics): $15 copay
Tier 2 (Preferred brand): $60 copay2
Tier 3 (Non-preferred brand): 60% of our allowance ($90 minimum)2
Tier 4 (Preferred specialty): $85 copay2
Tier 5 (Non-preferred specialty): $110 copay2

Mail Service Pharmacy:
Available to members with Medicare Part B primary only. 
Visit the Medicare page for more information.
Tier 1 (Generics): $20 copay
Tier 2 (Preferred brand): $100 copay
Tier 3 (Non-preferred brand): $125 copay

Specialty Pharmacy^:
Tier 4 (Preferred specialty): $85 copay2
Tier 5 (Non-preferred specialty): $110 copay2
Maternity Care $250 copay inpatient
$0 outpatient
Hospital Care

Inpatient (Precertification is required): $250 per day copay; up to $1,500 per admission

Outpatient: $150 copay per day per facility1


$150 copay in an office setting1

$200 copay in a non-office setting1

ER (accidental injury)

$250 copay per day per facility

ER (medical emergency)

$250 copay per day per facility

Lab work (such as blood tests) 15% our allowance1
Diagnostic services
(such as sleep studies, CT scans)

Up to $100 copay in an office1

Up to $200 copay in a hospital1

Chiropractic Care $30 copay per treatment; up to 20 visits per year1
Dental Care $30 copay per evaluation; up to 2 per year
Rewards Program

Earn $50 for completing the Blue Health Assessment3

Earn up to $120 for completing three eligible Online Health Coach goals3

Network Coverage In-network care only, except in certain situations like emergency care
Out-of-Pocket Maximum (PPO)

Self Only: $6,500

Self + One and Self & Family: $13,000

Annual Deductible No deductible

Under Basic Option, benefits are not available for services performed by Non-preferred providers, except in certain situations such as emergency care.

Cost sharing may not apply or may be different if Medicare is your primary coverage (it pays first).

  • ^ What you’ll pay for a 30-day supply of covered drugs.
  • 1 Under Basic Option you pay 30% of our allowance for agents, drugs and/or supplies you receive during your care.
  • 2 If you have Medicare Part B primary, your costs for prescription drugs may be lower.
  • 3 You must be the contract holder or spouse, 18 or older, on a Standard or Basic Option Plan to earn incentive rewards.

This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. Before making a final decision, please read the Plan’s federal brochure (RI 71-005). All benefits are subject to the definitions, limitations, and exclusions set forth in the federal brochure.

Get up to $800 back with a Medicare Reimbursement Account

Each member of a Basic Option plan who has Medicare Part A and Part B can get reimbursed up to $800 per year for paying their Medicare Part B premiums.

Learn More