What the Standard Option Plan Costs and Covers 2019

Summary of Benefits and Coverage Download (PDF)
HIP FEHB Standard Plan — HIP Prime HMO Download (PDF)

If you have questions about your plan benefits or would like to request a free printed copy of the Summary of Benefits and Coverage (“SBC”), please call Customer Service at 1-800-447-8255, Monday to Friday, 8 am to 6 pm (closed on weekends.) If you have a hearing or speech impairment and use a TDD, call 711.

Benefits At-a-Glance: HIP FEHB Standard Option — HIP Prime HMO

Standard Option - In Network
Medical Care
PCP office visit $30 copay
Specialist office visit $75 copay
Preventive Care
Routine physical exam $0 copay
Women’s wellness services $0 copay
Other Services
Outpatient mental health $30 PCP copay or $30 specialist copay
Urgent care $30 copay
Ambulatory surgery $150 copay
Ambulance $0 copay
Prescription drugs $25 generic/$50 brand/$100 non-formulary copay/$200 specialty drugs
Hospital Services
Inpatient care $250 copay
Anesthesia Included in hospital copay
Emergency room $250 copay (waived if admitted)

The chart above is a high level summary of benefits only. For complete details about the benefits available through this plan, please read the Federal RI 73-001. Coverage is subject to all terms, conditions, limitations and exclusions contained in [Federal RI 73-001].