Gold

BlueCHiP Direct

2300/4600

This is the lowest cost plan that Blue Cross offers in the gold tier. Your primary care physician directs most of your care and referrals to other doctors. This plan covers office visits and generic drugs before the deductible, and uses our local RI network, which includes all Rhode Island hospitals.

  • Full coverage for many preventive services, like an annual physical
  • Free dental exam, cleaning and annual exam for members under 19
  • Earn up to $250 (both subscriber and spouse) in wellness rewards and receive a 20% discount on thousands of CVS branded health items
  • $0 copayments for programs on quitting smoking, weight loss, and managing conditions like diabetes
  • This plan uses our RI network, which includes all Rhode Island hospitals, 1,620 primary care doctors, and 5,975 specialty doctors

Monthly premium

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316.94
BlueCHiP Direct 2300/4600
medical
2018
Gold
https://www.bcbsri.com/individual/shop/medical/2018/bluechip-direct-23004600

Who will be covered

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What's covered

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Medical & Hospital Benefits

Coverage

In-network you pay

Medical Coverage

Preventive Services

$0

Primary Care Provider (PCP) Office Visit when affiliated with a Patient Centered Medical Home (PCMH)

$15

PCP not affiliated with a PCMH

$35

Telemedicine

$35

Retail Clinic

$45

Specialist Visit

$45

Urgent Care Center

$75

Emergency Room

10% after deductible

Diagnostic Laboratory Tests

10% after deductible

X-rays

10% after deductible

High End Radiology (i.e., MRI, PET, and CAT scans etc.)

10% after deductible

Inpatient Hospital

10% after deductible

Pediatric Vision Eyeware (Dependents under 19)

Collection prescription glasses, lenses, and collection contact lenses

10% after deductible

Pediatric Dental (Dependent under 19)

Oral exams, cleanings, x-rays, fluoride treatments, sealants and space maintainers

$0

All other covered dental services 

50% after deductible

Prescription Drug Benefits

Coverage

In-Network You Pay

Tier 1 (Preferred Generic)

$10

Tier 2 (Non-preferred Generic)

$25

Tier 3 (Preferred Brand)

$50 after deductible

Tier 4 (Non-Preferred Brand)

$75 after deductible

Tier 5 (Specialty)

$125 after deductible

Monthly premium is an estimate based on the information you provided, and is not guaranteed. Your monthly premium is subject to change based on the benefits you select, the information you submit in your application, and other relevant factors.

This information is only a summary of benefits provided by the plan. It is not a contract. Other exceptions, reductions and limitations may also apply to your benefits. For details about coverage, please see the subscriber agreement for the plan or contact our Customer Service.

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622 George Washington
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