BlueCHiP for Medicare
Extra
This plan accommodates your busy, active lifestyle, offering flexible coverage even outside of the largest Medicare Advantage network in RI, plus many advantages like a fitness benefit, low PCP copays, and a low out-of-pocket maximum.
- $0 copay for PCMH PCP visits
- $25 specialist visits
- $0 labs/X-rays
- $0 for routine hearing and vision screenings
- $0 virtual doctors’ visits 24/7
- Flat dollar outpatient surgery copay
- Out-of-network coverage
- $0 drug deductible
- $0 Tier 1 and $4 Tier 2 prescription copays at preferred pharmacies
- $20 insulin copay (30-day supply) with Insulin Savings Program*
- Dental coverage built-in
- $75/quarter over-the-counter (OTC) benefit (Flexible Benefit Card)
- $100 annual wellness reimbursement
- $200/year allowance for dental, hearing, and vision (Flexible Benefit Card)
- $0 fitness benefit
- $0 rides
- $0 peer recovery services
- $15 acupuncture benefit
- $50 caregiver reimbursement
- 60 hours/year of household help
Call 1-800-505-2583 (TTY: 711)
Call (401) 277-2958 or 1-800-267-0439 (TTY: 711)
Monthly premium
$107.00
Come back at the start of the Annual Election Period (October 15) to select and enroll in a plan.
What's covered
See if your doctor and pharmacy are in the network
Medical & Hospital Benefits
Coverage
Copays & Details
Outpatient Care and Services1,2
Ambulance
$150/trip
Dental Services
Medicare-covered:
In-network: 20% of the cost
Out-of-network: 20% of the cost
Preventive: $0
Comprehensive: $0
$1,500 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
$150 for high-tech radiology services (for example, MRIs)
Out-of-network: 20% of the cost
Emergency Care
$90 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:
$200-$1,675 copay per hearing aid (2 aids every 3 years)
Outpatient Hospital/Surgery
In-network: Up to $250 copay per visit
Out-of-network: 20% of the cost
Primary Care Physician Visit
In-network:
$0 PCMH or $10 non-PCMH 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:
$200/year allowance for dental, hearing, and vision (Flexible Benefit Card)
Preventive Care
In-network: $0
Out-of-network: 20% of the cost
Inpatient Care1,2
Inpatient Hospital Care1
In-network: $300 copay per day for days 1-5 $0 Days 6+
Out-of-network: 20% of the cost
Our plan covers an unlimited number of days for an in-network inpatient hospital stay.
Skilled Nursing Facility
In-network:
$0 copay per day for days 1-20
$150 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.
Prescription Drug Benefits
Preferred
Standard
Prescription Deductible
No deductible
Initial Coverage (up to 30-day supply)3
Tier 1 (Preferred Generic)
$0 copay
$8 copay
Tier 2 (Non-preferred Generic)
$4 copay
$12 copay
Tier 3 (Preferred Brand)
$47 copay
$47 copay
Tier 4 (Non-Preferred Drug)
$100 copay
$100 copay
Tier 5 (Specialty Tier)
33% of the cost
33% of the cost
Mail Order (90-day Supply)
$0 copay for Tiers 1 and 2
Insulin Savings Program*
$20 (30 days)
$20 (30 days)
Plan Documents
* The Insulin Savings Program is not available to members who qualify for a low-income subsidy (LIS).
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 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 Deductible stage, Initial Coverage stage, Coverage Gap stage and the Catastrophic level stage.