2014 BlueCHiP for Medicare Standard with Drugs (HMO)

With a low monthly plan premium, BlueCHiP for Medicare Standard with Drugs provides coverage for preventive care, doctors' office visits, and hospital care as well as Medicare Part D prescription drugs and coverage for emergency care worldwide. You also have the Living Fit health club benefit.

*You must continue to pay your Medicare Part B premium.

Reason to choose this plan
  • Save with mail order
    Wellness Programs
Monthly Premium:
$48*
Part D Prescription Drug Coverage:
$4 for generic drugs; no deductible
In-Network Medical Out-of-Pocket Max:
$4,250
Enroll now

BlueCHiP for Medicare Standard with Drugs has a $48 monthly premium that provides comprehensive medical coverage within the network and covers Medicare Part D prescription drugs, including low copayments on many generic drugs. You also get wellness services like the Living Fit health club membership for $5 a month, one-on-one care coordination, and access to online health information.

Eligibility
If you are entitled to Medicare Part A, enrolled in Medicare Part B and live in our service area, which includes Bristol, Kent, Newport, Providence, and Washington counties, RI, you can join BlueCHiP for Medicare Standard with Drugs. Enrollment limitations do exist for individuals with End Stage Renal Disease. Call us for more details.

Already a BlueCHiP for Medicare Standard with Drugs member? We can also help you explore your plan.

Blue Cross & Blue Shield of Rhode Island is an HMO plan with a Medicare contract. Enrollment in Blue Cross & Blue Shield of Rhode Island depends on contract renewal.

Need assistance shopping for insurance?

We’re available by phone, TTY, or for walk-in service during the day.
1-800-505-BLUE (2583)
TTY 711.
See the Contact Us page for hours.

If you already have BlueCHiP for Medicare, please call Customer Service at
1-800-267-0439 or
TTY 711.

Here’s an overview of plan features.
  
Plan Features
Monthly Premium [1]$48
Out-of-pocket Maximum [2]$4,250
PCP office visits [2]$0-$10
Specialist office visits [2]$40
Inpatient hospitalization [2]

$650 per admission per benefit period

Inpatient mental health [2]

$650 per admission per benefit period

Skilled nursing facility [2]

Days 1-20: $25/day
Days 21-40: $150/day
Days 41-100: $0/day

Diagnostic tests, X-rays, and lab services [2]

$10 for Medicare-covered X-ray or Medicare-covered lab services
$150 for Medicare-covered diagnostic radiology services (MRI/CT) scan [3]

Home healthcare$0
Emergency [2]$65
Ambulance [2]

$200/trip

Nutritional counseling visits$0
Medicare-covered preventive services$0
Out-of-network costs for Point-of- Service Option

Not covered

Part B covered drugs [2]20%
  
Prescription drug copayments (up to 30-day supply) [4]
Tier 1 (generic)$4
Tier 2 (preferred-brand)$45
Tier 3 (non-preferred brand)$95
Tier 4 (speciality)33%
  
Additional Benefits
Living Fit

$5/month

Vision hardware

$100/year allowance

Hearing aids

Not Covered

  
Details: 

 

[1] Individuals must have both Medicare Part A and Part B to enroll. Individuals must continue to pay Medicare Part A premiums (if applicable) and Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.

[2] The out-of-pocket maximum includes only Medicare-covered services. This is the most a member would pay for these services during a calendar year. You must receive all routine care from plan providers unless you select the BlueCHiP for Medicare Value (HMO-POS) or the BlueCHiP for Medicare Preferred (HMO-POS) plan. If you select the BlueCHiP for Medicare Value or BlueCHiP for Medicare Preferred plan, with the exception of emergency or urgent care, ambulance, or dialysis services, it may cost more to get care from out-of-network providers.

[3] Review may include but is not limited to pre-authorization and/or continued treatment by the plan and/or plan designee. Contact Plan for details.

[4] If you select BlueCHiP for Medicare Core, Part D prescription drug coverage is not available with this plan. For all other plans, please refer to Chapter 6 of the Evidence of Coverage for prescription drug copayment information in a long-term care setting, as well as for mail order and extended day retail supplies. Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

The benefit information provided is a brief summary, not a complete description of benefits. Limitations, copayments, and restrictions may apply. For more information, please refer to the Evidence of Coverage. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of each year.

Key Documents

BlueCHiP for Medicare Plan Highlights
Highlights of all BlueCHiP for Medicare plans.
View Document (PDF)

Summary of Benefits
An overview of some of the features of all BlueCHiP for Medicare plan options to help you compare plans.
View Document (PDF)

Evidence of Coverage
A complete list of all of the benefits in your plan.
View Document (PDF)

Provider Directory
A list of plan doctors and healthcare providers.
View Document (PDF)

PCMH Listing
List of primary care physicians who are part of patient-centered medical homes (PCMH).
View Document (PDF)

Plan Ratings
The Medicare Program rates how well Medicare health and drug plans perform in different categories. This information is available to help you make the best choice.
View Document (PDF)

Privacy Practices

View Document (PDF)

Multi-language Interpreter Services

View Document (PDF)

Drug Coverage: 

Your Part D Coverage
Catamaran is BlueCHiP for Medicare’s pharmacy benefits manager and has contracts with pharmacies that equal or exceed CMS access requirements for pharmacy access in your area. The BlueCHiP for Medicare pharmacy network includes more than 65,000 pharmacies.

Find a local network pharmacy:
Pharmacy Directory (PDF 402KB)

Traveling or need to find a pharmacy out of state? Find a pharmacy anywhere in the country with this tool:
Pharmacy Locator Tool - Coming Soon

Get the Convenience of Mail Order!
Use our mail service pharmacy and receive a three-month supply of your medication at a lower overall copayment than if you purchased three one-month supplies at a retail pharmacy—and enjoy the convenience of delivery right to your home or vacation spot!

What’s Covered
Medicare Part D Prescription Drug Coverage
This plan covers Medicare Part D prescription drugs.

For a complete list of drugs covered by BlueCHiP for Medicare, see 2014 BlueCHiP for Medicare Comprehensive Formulary. To search for a drug within this document, use the search feature within Acrobat Reader.

Related Links

Additional information you may need about prescription drug coverage:

Prior Authorization Criteria

Part B vs. Part D Prior Authorization Criteria

Step Therapy Criteria

Quantity Limits

 

The following health and wellness benefits and services are available to all BlueCHiP for Medicare members:

Living Fit
Being active is one way you may improve your quality of life and help prevent or control conditions like diabetes and heart disease. Members receive the Living Fit benefit, which provides an unlimited-use membership at any network health club facility for just $5 per month. You pay month-to-month, and you may cancel your membership at any time.
View network health club facilities

Wellness Events
Blue Cross & Blue Shield of Rhode Island offers community-sponsored wellness events throughout the year at locations around Rhode Island.
View events

Blue365
Blue365℠ is an exclusive national program that provides valuable information, discounts, and offers on wellness products and services from industry-leading companies. This easy-to-use resource can help you make decisions about wellness while you save on healthy programs and services.
More...

The products and services described above are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the BlueCHiP for Medicare grievance process.

Health Center

  • Visit the Health Center to find answers to your health questions and resources that will help you lead a healthy life. You’ll find in-depth information about prescription and over-the-counter medications, Decision Points on dozens of medical tests, surgeries, and treatments, and useful interactive tools and quizzes.

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Last updated: 04/17/2014

H4152_2014website697 Approved

Blue Cross & Blue Shield of Rhode Island is an HMO plan with a Medicare contract. Enrollment in Blue Cross & Blue Shield of Rhode Island depends on contract renewal.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Visit Contact Us.

Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year.

You must continue to pay your Medicare Part B premium.