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MyBlue®:

Standard Option

Why choose between in-network and out-of-network care? With Standard Option, you get both.

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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 for primary care
$35 for specialists

35% of our allowance
Virtual Doctor Visits by Teladoc®

$0 for first 2 visits
$10 all additional visits

N/A
Urgent Care Center Accidental Injury: $0
Medical Emergency: $30 copay
Accidental Injury: $0
Medical Emergency: 35% of our allowance
Prescription Drugs Preferred Retail Pharmacy:
Tier 1 (Generics): $7.50 copay1
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 Pharmacy2:
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 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

In-Network Out-of-Network
Network Coverage In-network and out-of-network care In-network and out-of-network care
Out-of-Pocket Maximum

Self Only: $5,000

Self + One and Self & Family: $10,000

Self Only: $7,0004

Self + One and Self & Family: $14,0004

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.
 Subject to the calendar year deductible: $350 per person or $700 in total for Self + One or Self & Family contracts.
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