Monthly premium

268.22
BlueSolutions for HSA Direct 4100/8200
medical
2020
Silver
https://www.bcbsri.com/individual/shop/medical/2020/bluesolutions-hsa-direct-41008200-directonly

Who will be covered

Selecting this plan will add coverage for :

Silver

BlueSolutions for HSA Direct

4100/8200

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

  • Full coverage for many preventive services, like an annual physical, when you use a doctor in the national network
  • You receive tax advantages when you open an HSA
  • Includes dental and vision coverage for dependents under the age of 19
  • $0 copays for programs on quitting smoking, weight loss, and managing conditions like diabetes
  • Earn up to $250 (both subscriber and covered spouse) in wellness rewards
  • Member discounts with Blue 365 on gyms, nutrition services, fitness trackers, and more health and lifestyle brands
  • 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)

20% after deductible

PCP not affiliated with a PCMH

20% after deductible

Telemedicine

20% after deductible

Retail Clinic

20% after deductible

Specialist Visit

20% after deductible

Acupuncture Treatment

20% after deductible (12 visits per year)

Urgent Care Center

20% after deductible

Emergency Room

20% after deductible

Diagnostic Laboratory Tests

20% after deductible

X-rays

20% after deductible

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

20% after deductible

Inpatient Hospital

20% after deductible

Pediatric Vision Eyeware (Dependents under 19)

Collection prescription glasses, lenses, and collection contact lenses

20% 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)

$30 after deductible

Tier 3 (Preferred Brand)

$50 after deductible

Tier 4 (Non-Preferred Brand)

$75 after deductible

Tier 5 (Specialty)

$100 after deductible

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

Call (401) 459-5550 or just come by:
Cranston location
Cranston
Marshalls Plaza
1400 Oaklawn Ave.
East Providence location
East Providence
Highland Commons
71 Highland Ave.
Lincoln location
Lincoln
Lincoln Commons
622 George Washington Hwy.
Warwick location
Warwick
Cowesett Corners
300 Quaker Ln.
Visit Your Blue Store
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