BlueRI for Duals

BlueRI for Duals (HMO D-SNP)

New for 2022

This plan offers MORE benefits for $0 to members who are enrolled in both Medicare and Medicaid, all coordinated by a dedicated care team who makes accessing high-quality care and services easy!

  • $0 monthly premium
  • $0 copay for PCP & specialist visits
  • $0 labs/X-rays
  • $0/month fitness benefit
  • $0 rides
  • $0 drug deductible
  • $0 Tier 1 and $0 Tier 2 prescription copays
  • $0 virtual doctors’ visits 24/7
  • $0 peer recovery services
  • $0 acupuncture benefit
  • $0 non-skilled home health
  • $0 hearing aids
  • $100 caregiver reimbursement
  • $200 annual wellness reimbursement
  • $275/quarter over-the-counter (OTC) benefit
  • $300/year vision hardware allowance
  • Dental coverage built in

Monthly premium

$0.00


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Medical & Hospital Benefits

Coverage

Copays & Details

Outpatient Care and Services1,2

Ambulance

$0

Dental Services

Medicare-covered: $0
Preventive: $0
Comprehensive: $0
$3,000 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
You must use OneTouch plan-designated monitors and test strips.

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

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

Emergency Care

$0

Outpatient Hospital/Surgery

$0

Hearing Services

Routine hearing: $0
Non-routine hearing: $0 copay
Hearing aids:
$0 per hearing aid (2 aids every 3 years)

Primary Care Physician Visit

$0

Specialist Visit

$0

Vision Visit

Routine vision: $0
Non-routine vision: $0
Vision hardware:
Our plan pays up to $300 every year for eyewear.

Preventive Care

$0

Inpatient Care1,2

Inpatient Hospital Care

$0 Days 1 and beyond
Our plan covers an unlimited number of days for an in-network inpatient hospital stay.

Skilled Nursing Facility

$0 per day for days 1-100
Our plan covers up to 100 days in a skilled nursing facility.

Prescription Drug Benefits

Preferred

Standard

Prescription Deductible

No deductible

Initial Coverage (up to 30-day supply)3

Tier 1 (Preferred Generic)

n/a

$0 copay

Tier 2 (Non-preferred Generic)

n/a

$0 copay

Tier 3 (Preferred Brand)

n/a

Follow your "Extra Help" copays

Tier 4 (Non-Preferred Drug)

n/a

Follow your "Extra Help" copays

Tier 5 (Specialty Tier)

n/a

Follow your "Extra Help" copays

Mail Order (90-day Supply)

n/a

$0 for Tiers 1 and 2

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, 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 Summary of Benefits or 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, Coverage Gap stage and the Catastrophic level stage.

2022
(HMO D-SNP)
BlueRI for Duals
BlueRI for Duals (HMO D-SNP)
HMO D-SNP
0

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Call the Medicare Concierge team at (401) 277-2958 or 1-800-267-0439 (TTY: 711). Hours: Monday through Friday, 8:00 a.m. to 8:00 p.m.; Saturday, 8:00 a.m. to noon. (Open seven days a week, 8:00 a.m. to 8:00 p.m., October 1 - March 31.) You can use our automated answering system outside of these hours.

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Call us

Contact the Medicare Sales team at 1-800-505-BLUE (2583) (TTY: 711). Hours: Monday through Friday, 8:00 a.m. to 8:00 p.m. (Open seven days a week, 8:00 a.m. to 8:00 p.m., October 1 – March 31.) You can use our automated answering system outside of these hours.