Standard Option
Why choose between in-network and out-of-network care? With Standard Option, you get both.
Standard Option Benefits
See costs for typical services when you use Preferred providers.
| In-Network (PPO benefit) - You pay: |
Out-of-Network (Non-PPO benefit)* - You pay: |
|
|---|---|---|
| Preventive Care | Nothing for covered preventive screenings, immunizations and services |
35% of our allowance† |
| Physician Care |
$25 copay for primary care |
35% of our allowance† |
| Mental Health Visits | $25 copay | 35% of our allowance† |
| Virtual Doctor Visits by Teladoc® |
$0 for first 2 visits |
N/A |
| Urgent Care Center |
Accidental Injury: $0 Medical Emergency: $30 copay |
Accidental Injury: $0 Medical Emergency: 35% our our allowance† |
| Prescription Drugs |
Preferred Retail Pharmacy: Tier 1 (Generics): $7.50 copay^1 Tier 2 (Preferred brand): 30% of our allowance Tier 3 (Non-preferred brand): 50% of our allowance Tier 4 (Preferred specialty): 30% of our allowance^ Tier 5 (Non-preferred specialty): 30% of our allowance^ Mail Service Pharmacy: Tier 1 (Generics): $15 copay1 Tier 2 (Preferred brand): $90 copay Tier 3 (Non-preferred brand): $125 copay Specialty Pharmacy^2 Tier 4 (Preferred specialty): $65 copay Tier 5 (Non-preferred specialty): $85 copay |
Retail Pharmacy: 45% of our allowance Mail Service Pharmacy: Not covered Specialty Pharmacy: Not covered |
| Maternity Care | $0 copay |
Pre-/postnatal professional care: 35% of our allowance† Inpatient hospital: $450 per admission copay for unlimited days, plus 35% of our allowance Outpatient facility care: 35% of our allowance† |
| Hospital Care |
Inpatient (Precertification is required): $350 per admission Outpatient: 15% of our allowance† |
Inpatient (Precertification is required): $450 per admission copay, plus 35% of our allowance Outpatient: 35% of our allowance† |
| Surgery |
15% of our allowance† |
35% of our allowance†* |
| ER (accidental injury) | $0 within 72 hours |
Nothing for covered services |
| ER (medical emergency) |
15% of our allowance† |
15% of our allowance† |
| Lab work (such as blood tests) |
15% of our allowance† |
35% of our allowance† |
| Diagnostic services (such as sleep studies, X-rays, CT scans) |
15% of our allowance† |
35% of our allowance† |
| Chiropractic Care |
$25 copay per treatment; up to 12 visits per year |
35% of our allowance† up to 12 visits per year |
| Dental Care | The difference between the fee schedule amount and the Maximum Allowable Charge (MAC) |
35% of our allowance† |
| Rewards Program |
Earn $50 for completing the Blue Health Assessment.3 Earn up to $120 for completing three eligible Online Health Coach goals.3 |
Earn $50 for completing the Blue Health Assessment.3 Earn up to $120 for completing three eligible Online Health Coach goals.3 |
| Network Coverage |
In-network and out-of-network care |
In-network and out-of-network care |
| Out-of-Pocket Maximum |
Self Only: $6,000 Self + One and Self & Family: $12,000 |
Self Only: $8,0004 Self + One and Self & Family: $16,0004 |
| Annual Deductible |
Self Only: $350 Self + One and Self & Family: $700 |
Self Only: $350 Self + One and Self & Family: $700 |
Cost sharing may not apply or may be different if Medicare is your primary coverage (it pays first)
- * If you use a Non-preferred provider under Standard Option, you generally pay any difference between our allowance and the billed amount, in addition to any share of our allowance shown in the table above. Certain out-of-pocket costs do not apply if Medicare is your primary coverage for medical services (it pays first).
- † Subject to the calendar year deductible: $350 per person or $700 in total for Self + One or Self & Family contracts.
- ^ What you’ll pay for a 30-day supply of covered drugs.
- 1 If you have Medicare Part B primary, your costs for prescription drugs may be lower.
- 2 On limited occasions, such as for certain drugs that require prior approval, you will need to file a claim for services received from Preferred providers.
- 3 You must be the contract holder or spouse, 18 or older, on a Standard or Basic Option Plan to earn incentive rewards.
- 4 Eligible expenses for the services of Preferred (In-Network) providers also count toward these limits.
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 prescriptions delivered right to your door
All Standard Option members get access to our Mail Service Pharmacy Program. It's a convenient way to get any prescription drugs you take regularly sent to your home.
Learn More