2023

BlueCHiP for Medicare

Value

Consider this plan if cost is most important to you. Combining a $0 monthly premium with the state's largest Medicare Advantage network, this plan provides comprehensive benefits, network flexibility, and many extras, like a new Flexible Benefit Card and an annual wellness reimbursement.

  • $0 monthly premium
  • $0 copay for PCMH PCP visits
  • $30 specialist visits
  • $0 labs/X-rays
  • $0 for routine hearing and vision screenings
  • $0 virtual doctors' visits 24/7
  • Out-of-network coverage
  • $0 drug deductible
  • $0 Tier 1 and Tier 2 prescription copays at preferred pharmacies
  • $20 insulin copay (30-day supply) with Insulin Savings Program*
  • Dental coverage built-in
  • $60/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
  • Flat dollar outpatient surgery copay
  • 60 hours/year of household help
Qualify for Extra Help and/or Medicaid?
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Need help?
Call 1-800-505-2583 (TTY: 711)
Need help?
Call (401) 277-2958 or 1-800-267-0439 (TTY: 711)

Monthly premium

$0.00

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What's covered

See if your doctor and pharmacy are in the network

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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: 50% of the cost for covered services
$1,000 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
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: $30 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 $30 non-PCMH copay per visit
Out-of-network: 20% of the cost

Specialist Visit

In-network: $30 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: $30 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 Care

In-network: $375 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
$180 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)

$0 copay

$16 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 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.