FEP Blue Standard™ Benefits Chart (2024)

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

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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	$30copay for primary care $40copay 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): $65copay Tier 5 (Non-preferred specialty): $85copay	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	$30copay 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

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	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

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.

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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.

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FEP Blue Standard™ Benefits Chart (2024)