Skip to main content
MyBlue®:

Standard Option

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

Enroll Now

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

$30 copay for primary care

$40 copay for specialists

$30 copay for mental health visits

35% of our allowance
Virtual Doctor Visits by Teladoc®

$0 for first 2 visits and all nutrition visits
$10 all additional 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

$30 copay per treatment; up to 12 visits a year

35% of our allowance up to 12 visits a 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 Daily Habits goals.3

 

Earn $50 for completing the Blue Health Assessment.3

 

Earn up to $120 for completing three eligible Daily Habits 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

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 copay for specialists

35% of our allowance
Mental Health Visits $25 copay 35% of our allowance
Virtual Doctor Visits by Teladoc®

$0 for first 2 visits
$10 copay all additional 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

Standard 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.

Standard Option with MPDP
In-network Retail Pharmacy

Tier 1 (Generics): $5 for up to a 30-day supply; $15 for a 31 to 90-day supply

Tier 2 (Preferred brand name): 15% of our allowance for up to a 90-day supply

Tier 3 (Non-preferred brand name): 50% of our allowance for up to a 90-day supply

Tier 4 (Specialty drugs): $60 for up to a 30-day supply; $170 for a 31 to 90-day supply

FEP Mail Service Pharmacy

Tier 1 (Generics): $5 copay

Tier 2 (Preferred brand name): $85 copay

Tier 3 (Non-preferred brand name): $125 copay

Tier 4 (Specialty drugs): $150 copay

Annual Pharmacy Out-of-Pocket Maximum5 $2,000 per member

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.

5 You still have an overall medical out-of-pocket maximum. Your MPDP pharmacy out-of-pocket maximum is part of it, not added to it.

 

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.

Try our Prescription Drug Cost Tool

Our Prescription Drug Cost Tool lets you check drug costs 24/7. See if your drug is covered under your current plan and compare costs of covered drugs for all three plans.

Check Drug Costs

Get prescriptions delivered right to your door

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

Already a member? Get started

Sign up for MyBlue

To get the most out of your coverage, create a MyBlue account.

Learn More

Update your contact information

Make sure your information is current in MyBlue.

Learn More

Download the fepblue app

Get our free app to access your benefits on the go.

Learn More