Basic Option
Stay in network for care. Basic Option gives you access to our Preferred provider network that includes over 1.7 million doctors and hospitals 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 |
$35 copay for primary care1 $45 copay for specialists1$35 copay for mental health visits |
| Virtual doctor visits by Teladoc® |
$0 for first 2 visits and all nutrition visits $15 all additional visits |
| Urgent Care Center | $35 copay |
| Prescription Drugs |
Preferred Retail Pharmacy^:
Tier 1 (Generics): $20 copay |
| 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 |
| Surgery |
$150 per surgeon in an office1 $200 per surgeon in other settings1 |
| ER (accidental injury) |
$250 per day per facility |
| ER (medical emergency) |
$250 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 |
$35 for up to 20 visits a year1 |
| Dental Care |
$35 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 Daily Habits 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 |
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 |
| 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 |
| Surgery |
$150 copay in an 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 |
| 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 |
Basic Option with FEP Medicare Prescription Drug Program
Eligible members with Medicare get lower out-of-pocket costs for higher cost drugs and additional approved prescription drugs in some tiers than the traditional pharmacy benefit. Learn more here.
| Basic Option with MPDP | ||
|---|---|---|
| Preferred Retail Pharmacy |
Tier 1 (Generics): $10 for up to a 30-day supply; $30 for a 31 to 90-day supply Tier 2 (Preferred brand name): $45 for up to a 30-day supply; $135 for a 31 to 90-day supply Tier 3 (Non-preferred brand name): 50% of our allowance ($60 min) for up to a 30-day supply; $175 min for a 31 to 90-day supply Tier 4 (Specialty drugs): $75 for up to a 30-day supply; $195 for a 31 to 90-day supply |
|
| Mail Service Pharmacy |
Tier 1 (Generics): $15 copay Tier 2 (Preferred brand name): $95 copay Tier 3 (Non-preferred brand name): $125 copay Tier 4 (Specialty drugs): $150 copay |
|
| FEP Specialty Pharmacy | Your specialty drug benefits are in Tier 4 (see above) for a 30-day supply | |
| Annual Prescription Drug Out-of-Pocket Maximum | $3,250 per member |
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.
The FEP Medicare Prescription Drug Program is a prescription drug plan with a Medicare contract. Enrollment in MPDP depends on contract renewal.
The formulary and/or pharmacy network may change at any time. You will receive notice when necessary.
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