Monthly premium
This Extra (HMO-POS) plan accommodates your busy, active lifestyle, combining flexible coverage – even outside of the largest Medicare Advantage network in Rhode Island – with the lowest out-of-pocket maximum. This plan also offers the strongest vision and dental benefits (including crowns), as well as a Flexible Benefit Card and a gym and home fitness benefit.
Consider this plan if you are expecting to have higher medical needs.
Not sure what plan you need? Use the plan recommendation tool.
Medical
- $0 copay for PCP visits
- $0 labs/X-rays
- $25 specialist visits
- $25 physical/speech/occupational therapy
- Out-of-network coverage
Prescription Drugs
- $0 drug deductible
- $0 Tier 1 and Tier 2 prescription copays
- Discounted copays for a 100-day supply with Preferred Mail Order
Dental/Hearing/Vision
- $0 preventive and comprehensive dental (including crowns)
- $2,500/year dental benefit maximum
- $0 for routine hearing and vision screenings
- 2 hearing aids, starting at $0, annually
- Get $300/year for dental and hearing on a Flexible Benefit Card
- Get $400/year for eyewear
Extras
- $0 gym and home fitness benefit
- Get $100/quarter over-the-counter (OTC) benefit for everyday health items (Flexible Benefit Card)
Tools to help you choose:
See if your doctor and pharmacy are in the network
Ambulance
$175 copay per trip
Dental Services
Medicare-covered
In-network: 20% of the cost
Out-of-network: 20% of the cost
Preventive: $0
Comprehensive: $0
$2,500 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
$100 for high-tech radiology services (for example, MRIs)
Out-of-network
20% of the cost
Emergency Care
$100 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 $225 copay per visit for ambulatory surgical center based services.
Up to $275 copay per visit for hospital based services.
Out-of-network:
20% of the cost
Primary Care Provider Visit
In-network
$0 PCP 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 $400/year allowance for vision hardware.
Preventive Care
In-network: $0
Out-of-network: 20% of the cost
Inpatient Hospital Care1
In-network
$275 copay per day for days 1-5
$0 Days 6+
Out-of-network
20% of the cost
Skilled Nursing Facility (SNF)
In-network
$0 copay per day for days 1-20
$214 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.
No deductible
Tier 1 (Preferred Generic)
$0 copay
Tier 2 (Non-preferred Generic)
$0 copay
Tier 3 (Preferred Brand)
$47 copay
Tier 4 (Non-preferred Drug)
$100 copay
Tier 5 (Specialty Tier)
33% of the cost
Mail Order (100-day Supply)
$0 copay for Tiers 1 and 2
Insulins (30-day Supply)
$35
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 Enhanced (HMO-POS), BlueCHiP for Medicare Extra (HMO-POS), BlueCHiP for Medicare Preferred (HMO-POS), or the BlueCHiP for Medicare Access (HMO-POS) plan. If you select the BlueCHiP for Medicare Value, BlueCHiP for Medicare Enhanced (HMO-POS), BlueCHiP for Medicare Extra, BlueCHiP for Medicare Preferred, or the BlueCHiP for Medicare Access (HMO-POS) 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 Initial Coverage stage, and the Catastrophic level stage.