![]() ^ What you’ll pay for a 30-day supply of covered drugs.ġ Deductible applies. Under FEP Blue Focus, benefits are not available for services performed by Non-preferred providers, except in certain situations such as emergency care.Ĭost sharing may not apply or may be different if Medicare is your primary coverage (it pays first). $25 copay per treatment for up to 10 visits per year combined for chiropractic care and acupuncture 5Įarn a reward at no out-of-pocket cost for getting an annual physical 6 ![]() ![]() Tier 2 (Preferred Generic specialty, and Preferred brand specialty): 40% of our allowance ($350 maximum) 2 Tier 2 (Preferred brand): 40% of our allowance ($350 max) 2 Preferred Retail Pharmacy ^ Tier 1 (Generics): $5 copay $10 copay per visit for your first 10 primary and/or specialty care visits combined 5 $10 copay per visit for your first 10 primary and/or specialty care visits combined 5 In-network care only, except in certain situations like emergency care Inpatient (Precertification is required): 30% of our allowance 1ĭiagnostic services (such as sleep studies, X-rays, CT scans)Įarn a reward, such as a $150 MyBlue Wellness Card, at no out-of-pocket cost for getting an annual physical 6 Tier 2 (Preferred specialty): 40% of our allowance ( $350 maximum) 2 Tier 2 (Preferred brand): 40% of our allowance ( $350 maximum) 2 Preferred Retail Pharmacy ^: Tier 1 (Generics): $5 copay $0 for first 2 visits and all nutrition visits $10 per visit for your first 10 primary and/or specialty care visits combined medical and mental health substance use 5 Nothing for covered preventive screenings, immunizations and services
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