(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

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

Deductibles

In-network

Individual

$1,200

Family

$2,400

Out-of-Pocket Limits

In-network

Individual

$3,800

Family

$7,600


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)

First non preventive pcp visit free
Subsequent visits $15

PCP not affiliated with a PCMH

First non preventive pcp visit free
Subsequent visits $35

Telemedicine

$35

Retail Clinic

$50

Specialist Visit

$50

Annual foot and eye exam for members with diabetes

$0

Urgent Care Center

$75

Emergency Room

$200

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

Pediatric Vision Eyeware (Dependents under 19)

Collection prescription glasses, lenses, and collection contact lenses

$0

Prescription Drug Benefits

Tier 1 (Preferred Generic)

$10

Tier 2 (Non-preferred Generic)

$25

Tier 3 (Preferred Brand)

$50

Tier 4 (Non-Preferred Brand)

$75

Tier 5 (Specialty)

$125

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

$2

COVERAGE TYPE
Dental Benefits

Dental Benefits

Exams, X-Rays, Cleanings, Palliative Treatment

$0

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+)