BlueCHiP for Medicare


Offering low out-of-pocket costs, the state’s largest Medicare Advantage network, and additional medical benefits like vision, hardware, and wig allowances, this plan provides comprehensive coverage to meet many needs.

  • $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
  • $0 drug deductible
  • $3 Tier 1 and $6 Tier 2 prescription copays at preferred pharmacies
  • $20 insulin copay (30-day supply) with Insulin Savings Program*
  • Dental coverage built-in
  • $100/quarter over-the-counter (OTC) benefit (Flexible Benefit Card)
  • $200/year allowance for dental, hearing, and vision (Flexible Benefit Card)
  • $0 fitness benefit
  • $0 rides
  • $0 peer recovery services
  • $75 emergency room copay
  • $75 ambulance copay
  • $150 outpatient surgery copay
  • Hearing aids for $200-$1,675 copay per ear in-network
  • $350 wig allowance
  • 60 hours/year of household help
Need help?
Call 1-800-505-2583 (TTY: 711)
Need help?
Call (401) 277-2958 or 1-800-267-0439 (TTY: 711)

Monthly premium


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What's covered

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Copays & Details

Outpatient Care and Services1,2



Dental Services

Medicare-covered: 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

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
$150 for high-tech radiology services (for example, MRIs)

Emergency Care

$75 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.

Outpatient Hospital/Surgery

Up to $150 copay per visit

Hearing Services

Routine hearing: $0
Non-routine hearing: $25 copay per visit
Hearing aids: $200-$1,675 copay per hearing aid (2 aids every 3 years)

Primary Care Physician Visit

$0 PCMH or $5 non-PCMH copay per visit

Specialist Visit

$25 copay per visit
Referral is required for specialist visits.

Vision Visit

Routine vision: $0
Non-routine vision: $25 copay per visit

Vision hardware:
$200/year allowance for dental, hearing, and vision (Flexible Benefit Card)

Preventive Care


Inpatient Care1,2

Inpatient Hospital Care

$190 copay per day for days 1-5, $0 Days 6+
Our plan covers an unlimited number of days for an inpatient hospital stay.

Skilled Nursing Facility

$0 copay per day for days 1-20
$135 copay per day for days 21-45
$0 copay per day for days 46-100
Our plan covers up to 100 days in a SNF.



Prescription Deductible

No deductible

Initial Coverage (up to 30-day supply)3

Tier 1 (Preferred Generic)

$3 copay

$11 copay

Tier 2 (Non-preferred Generic)

$6 copay

$14 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)

* 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.