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

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

2017 VantageBlue Direct 1200/2400 with Dental

NOTE: This plan will not be offered in 2018. If you choose this plan for 2017, you will automatically be enrolled in a different plan for 2018: VantageBlue Direct 1325/2650. You will need to enroll in a separate dental plan for 2018. We can help you consider your options for both medical and dental plans. Call 1 (855) 690-2583 (my0blue).

This plan gives you the highest levels of medical and dental coverage. You will have access to our national network of doctors, dentists, labs, and hospitals, with no referral required.

  • Provides coverage for most office visits before deductible
  • Full coverage for many preventive services, like an annual physical, dental exam, xrays, and cleanings.
  • Includes dental and vision coverage for dependents under the age of 19
  • $2 copayments for certain prescription drugs used to treat diabetes, asthma and chronic obstructive pulmonary disorders (COPD)
  • $0 copayments for an annual foot and eye exam for members with diabetes
  • $0 copayments for programs on quitting smoking, and managing conditions like asthma and diabetes
  • Earn up to $250 (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
  • View benefit information on Your Blue Touch RI mobile app







Out-of-Pocket Limits






What is covered?

In-Network You Pay

Medical and Hospital Benefits

Medical Coverage

Preventive Services


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

First non preventive pcp visit free
Subsequent visits $15

PCP not affiliated with a PCMH

First non preventive pcp visit free
Subsequent visits $35



Retail Clinic


Specialist Visit


Annual foot and eye exam for members with diabetes


Urgent Care Center


Emergency Room


Diagnostic Laboratory Tests

10% after deductible


10% after deductible

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

10% after deductible

Pediatric Vision Eyeware (Dependents under 19)

Collection prescription glasses, lenses, and collection contact lenses


Prescription Drug Benefits

Tier 1 (Preferred Generic)


Tier 2 (Non-preferred Generic)


Tier 3 (Preferred Brand)


Tier 4 (Non-Preferred Brand)


Tier 5 (Specialty)


Certain maintenance prescriptions for diabetes, asthma, and chronic obstructive pulmonary disease (COPD)


Dental Benefits

Dental Benefits

Exams, X-Rays, Cleanings, Palliative Treatment


Fluoride, Sealants, Space Maintainers

$0 (under age 19)
Not Covered (age 19+)

Fillings, Simple Extractions, Denture Repairs, Relines, Rebasing, Periodontal Maintenance, GA/IV Sedation, Root Canals, Periodotal Services, Oral Surgery

20% after deductible

Crowns & Onlays and Prosthodontics

50% after deductible

Medically Necessary Orthodontics

50% after deductible (under age 19)

Not Covered (age 19+)