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.
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 for primary care1 |
| Virtual doctor visits by Teladoc® |
$0 for first 2 visits |
| Urgent Care Center | $35 copay |
| Prescription Drugs |
Preferred Retail Pharmacy: Tier 1 (Generics): $10 copay Tier 2 (Preferred brand): $55 copay2 Tier 3 (Non-preferred brand): 60% of our allowance ($75 minimum)2 Tier 4 (Preferred specialty): $65 copay2 Tier 5 (Non-preferred specialty): $90 copay2 Mail Service Pharmacy: Available to members with Medicare Part B primary only. Visit the Medicare page for more information. Tier 1 (Generics): $20 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 |
$175 inpatient $0 outpatient |
| Hospital Care |
Inpatient (Precertification is required): $175 per day; up to $875 per admission Outpatient: $100 per day per facility1 |
| Surgery |
$150 in an office setting1 $200 in a non-office setting1 |
| ER (accidental injury) |
$175 per day per facility |
| ER (medical emergency) |
$175 per day per facility |
| Lab work (such as blood tests) | $0 copay1 |
|
Diagnostic services (such as sleep studies, CT scans) |
Up to $100 in an office1 Up to $150 in a hospital1 |
| Chiropractic Care | $30 per treatment; up to 20 visits per year |
| 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 |
| Basic Option | |
|---|---|
| Network Coverage | In-network care only, except in certain situations like emergency care |
| Out-of-Pocket Maximum (PPO) |
Self Only: $5,500 Self + One and Self & Family: $11,000 |
| 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).
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