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2024
BlueCHiP for Medicare
Extra

Monthly premium

$105.00
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This plan accommodates your busy, active lifestyle, offering flexible coverage even outside of the largest Medicare Advantage network in RI, plus many advantages like a fitness benefit, low PCP copays, and a low out-of-pocket maximum.

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Medical

  • $0 copay for PCMH PCP visits
  • $0 labs/X-rays
  • $0 virtual doctors' visits 24/7
  • $15 acupuncture benefit
  • $25 specialist visits
  • Flat dollar outpatient surgery copay
  • Out-of-network coverage

Prescription Drugs

  • $0 drug deductible
  • $0 Tier 1 and $4 Tier 2 prescription copays at preferred pharmacies
  • $20 preferred insulin copay (30-day supply) or $50 (90-day). Copays will not increase, even through the coverage gap.*

Dental/Hearing/Vision

  • $0 preventive and comprehensive dental
  • $0 for routine hearing and vision screenings
  • 2 hearing aids, starting at $0, annually
  • $200 vision hardware allowance
  • $220/year allowance for dental and hearing (Flexible Benefit Card)

Extras

  • $75/quarter over-the-counter (OTC) benefit for everyday health items (Flexible Benefit Card)
  • $100 annual wellness reimbursement
  • $0 fitness benefit
  • $0 rides
  • 40 hours/year of household help

What's covered

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Coverage
Copays & Details
Outpatient Care and Services1,2

Ambulance

$150/trip

Dental Services

Medicare-covered
In-network: 20% of the cost
Out-of-network: 20% of the cost

Preventive: $0
Comprehensive: $0

$1,500 limit on all covered dental services for preventive and comprehensive dental services. All preventive and comprehensive services must be provided by an in-network plan-contracted dentist.

Diabetes Supplies and Services

In-network: $0
Out-of-network: 20% of the cost

You must use OneTouch plan-designated monitors and test strips.

Diagnostic Tests, Lab and Radiology Services, and X-rays

In-network
$0 for lab services
$0 for diagnostic tests and X-rays
$150 for high-tech radiology services (for example, MRIs)

Out-of-network
20% of the cost

Emergency Care

$90 copay per visit

If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care.

Hearing Services

Routine hearing
In-network: $0
Out-of-network: 20% of the cost

Non-routine hearing
In-network: $25 copay per visit
Out-of-network: 20% of the cost

Hearing aids
$0-$1,475 copay per hearing aid (2 aids every 3 years)

Outpatient Hospital/Surgery

In-network: Up to $250 copay per visit
Out-of-network: 20% of the cost

Primary Care Provider Visit

In-network
$0 PCMH or $5 non-PCMH copay per visit

Out-of-network
20% of the cost

Specialist Visit

In-network: $25 copay per visit
Out-of-network: 20% of the cost

Referral is required for specialist visits.

Vision Visit

Routine vision
In-network: $0
Out-of-network: 20% of the cost

Non-routine vision
In-network: $25 copay per visit
Out-of-network: 20% of the cost

Vision Hardware
Our plan offers a $200/year allowance for vision hardware.

Preventive Care

In-network: $0
Out-of-network: 20% of the cost

Inpatient Care1,2

Inpatient Hospital Care1

In-network: $300 copay per day for days 1-5 $0 Days 6+
Out-of-network: 20% of the cost

Our plan covers an unlimited number of days for an in-network inpatient hospital stay.

Skilled Nursing Facility (SNF)

In-network
$0 copay per day for days 1-20
$150 copay per day for days 21-45
$0 copay per day for days 46-100

Out-of-network
20% of the cost

Our plan covers up to 100 days in a SNF.

 
Preferred
Standard
Prescription Deductible

No deductible

Initial Coverage (up to 30-day supply)3

Tier 1 (Preferred Generic)

$0 copay

$8 copay

Tier 2 (Non-preferred Generic)

$4 copay

$12 copay

Tier 3 (Preferred Brand)

$47 copay

$47 copay

Tier 4 (Non-preferred Drug)

$100 copay

$100 copay

Tier 5 (Specialty Tier)

33% of the cost

33% of the cost

Preferred Mail Order (90-day Supply)

$0 copay for Tiers 1 and 2

 

Preferred Insulins (30-day Supply)

$20

 

*$20 preferred insulin copay (30-day supply) or $50 (90-day) for preferred insulins on Tier 3. Tier 4 formulary insulins will have a $35 (30-day supply) or $105 (90-day) copay.

1 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), BlueCHiP for Medicare Extra (HMO-POS), BlueCHiP for Medicare Preferred (HMO-POS), or the HealthMate for Medicare (PPO) plan. If you select the BlueCHiP for Medicare Value, BlueCHiP for Medicare Extra, BlueCHiP for Medicare Preferred, or the HealthMate for Medicare 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.

2 A preauthorization may be required. 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.

3 You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances, quantity limitations and restrictions may apply. Please refer to the Evidence of Coverage for prescription drug cost share information in a long-term care setting, mail order, and extended day retail supplies as well as detailed benefit information concerning the Deductible stage, Initial Coverage stage, Coverage Gap stage, and the Catastrophic level stage.