FEP Blue Standard™
Why choose between in-network and out-of-network care? With FEP Blue Standard, you get both.
FEP Blue Standard™ 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 |
|
35% of our allowance† |
| Virtual Doctor Visits by Teladoc® |
|
N/A |
| Urgent Care Center |
|
|
| Prescription Drugs |
Preferred Retail Pharmacy:
Mail Service Pharmacy:
Specialty Pharmacy^2
|
Retail Pharmacy:
Mail Service Pharmacy:
Specialty Pharmacy:
|
| Maternity Care | $0 copay | |
| Hospital Care |
|
|
| 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 |
|
|
| Network Coverage |
In-network and out-of-network care |
In-network and out-of-network care |
| Out-of-Pocket Maximum |
|
|
| Annual Deductible |
|
|
FEP Blue Standard™ 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.
| FEP Blue Standard™ with MPDP | |
|---|---|
| In-network Retail Pharmacy |
|
| FEP Mail Service Pharmacy |
|
| 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 FEP Blue Standard, 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 FEP Blue Standard or FEP Blue Basic™ 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.
Get prescriptions delivered right to your door
FEP Blue Standard™ 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.
