Monthly premium

383.66
BlueSolutions for HSA Direct 1400/2800
medical
2019
Gold
https://www.bcbsri.com/individual/shop/medical/2019/bluesolutions-hsa-direct-14002800-directonly

Who will be covered

Selecting this plan will add coverage for :

Gold

BlueSolutions for HSA Direct

1400/2800

This plan offers a high level of coverage once you meet your deductible with the added benefit of an optional health savings account to pay for medical expenses. You’ll have access to our national network of doctors (across all 50 states), labs, and hospitals.

  • Full coverage for many preventive services, like an annual physical
  • You receive tax advantages when you open a health savings account
  • Includes dental and vision coverage for dependents under the age of 19
  • $0 copayments for programs on quitting smoking, and managing conditions like asthma and diabetes
  • Earn up to $250 (both subscriber and covered spouse) in wellness rewards and receive a 20% discount on CVS branded health items
  • View benefit information on Your Blue Touch RI mobile app

What's covered

See if your doctor is in the network
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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 after deductible

PCP not affiliated with a PCMH

$35 after deductible

Telemedicine

$0 after deductible

Retail Clinic

$40 after deductible

Specialist Visit

$40 after deductible

Acupuncture Treatment

$45 after deductible (12 visits per year)

Urgent Care Center

$75 after deductible

Emergency Room

$150 after deductible

Diagnostic Laboratory Tests

$0 after deductible

X-rays

$0 after deductible

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

$150 after deductible

Inpatient Hospital

$200 per admission after deductible

Pediatric Vision Eyeware (Dependents under 19)

Collection prescription glasses, lenses, and collection contact lenses

$0 after deductible

Pediatric Dental (Dependent under 19)

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

$0 after deductible

All other covered dental services 

50% after deductible

Prescription Drug Benefits

Coverage

In-Network You Pay

Tier 1 (Preferred Generic)

$10 after deductible

Tier 2 (Non-preferred Generic)

$25 after deductible

Tier 3 (Preferred Brand)

$50 after deductible

Tier 4 (Non-Preferred Brand)

$75 after deductible

Tier 5 (Specialty)

$125 after deductible

You want the right plan. We can help you choose.

Call (401) 459-5550 or just come by:
Warwick location
Warwick
Cowesett Corners
300 Quaker Lane
East Providence location
East Providence
Highland Commons
71 Highland Avenue
Lincoln location
Lincoln
Lincoln Mall Shopping Center
622 George Washington Hwy
Visit Your Blue Store
Or send our sales team a message

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