(401) 459-5550, or 1-855-690-2583 (my0blue)

Monday - Friday, from 8:00 a.m. - 5:00 p.m.

2017 BasicBlue Direct 4900/9800

A plan that covers office visits and generic drugs before the deductible while also providing comprehensive coverage after you meet the deductible. You have access to our national network of doctors, labs, and hospitals, with no referral required.

  • Provides coverage for most office visits and generic drugs before deductible
  • Access to 90 percent of doctors and hospitals across 50 states
  • Certain over-the-counter preventive medications are FREE when purchased at a participating pharmacy with a prescription
  • Earn up to $250 (both subscriber and covered spouse) in wellness rewards and receive a 20% discount on thousands of CVS branded health items
  • 24/7 phone access to care through the Nurse Care Line
  • Free dental exam, cleaning and annual exam for members under 19
  • View benefit information on Your Blue Touch RI mobile app
  • Full coverage for many preventive services, like an annual physical
  • $0 copayments for programs on quitting smoking, weight loss, and managing conditions like diabetes

Deductibles

In-network

Individual

$4,900

Family

$9,800

Out-of-Pocket Limits

In-network

Individual

$5,500

Family

$11,000


What is covered?

COVERAGE TYPE
In-Network You Pay

Medical and Hospital Benefits

Medical Coverage

Preventive Services

$0

Primary Care Provider (PCP) Office Visit when affiliated with a Patient Centered Medical Home (PCMH)

1 to 4 non preventive visits $10
5+ non preventive visits $10 after deductible

PCP not affiliated with a PCMH

1 to 4 non preventive visits $20
5+ non preventive visits $20 after deductible

Telemedicine

$20

Retail Clinic

$45

Specialist Visit

$45

Urgent Care Center

$75 after deductible

Emergency Room

10% after deductible

Diagnostic Laboratory Tests

10% after deductible

X-rays

10% after deductible

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

10% after deductible

Inpatient Hospital

10% after deductible

Pediatric Vision Eyeware (Dependents under 19)

Collection prescription glasses, lenses, and collection contact lenses

10% after deductible

Pediatric Dental (Dependent under 19)

Oral exams, cleanings, x-rays, fluoride treatments, sealants and space maintainers

$0

All other covered dental services

50% after deductible

Prescription Drug Benefits

Tier 1 (Preferred Generic)

$10

Tier 2 (Non-preferred Generic)

$30

Tier 3 (Preferred Brand)

$50 after deductible

Tier 4 (Non-Preferred Brand)

$75 after deductible

Tier 5 (Specialty)

$100 after deductible