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

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

2018 BlueCHiP Direct Advance 4650/9300

This is the lowest-cost plan that Blue Cross offers in the Silver tier. Your primary care provider (PCP) coordinates your healthcare as well as referrals for other doctors and labs. This plan covers office visits and most generic drugs before the deductible. You have access to a tailored network of high-quality doctors, hospitals, and labs in Rhode Island.

  • Full coverage for many preventive services, like an annual physical
  • Free dental exam, cleaning and annual exam for members under 19
  • Earn up to $250 (both subscriber and spouse) in wellness rewards and receive a 20% discount on thousands of CVS branded health items
  • $0 copayments for programs on quitting smoking, weight loss, and managing conditions like diabetes
  • This plan uses a tailored, RI network, which includes all Lifespan hospitals, over 200 primary care providers, and over 1700 specialty doctors.
    Major RI hospitals:
    • Rhode Island Hospital
    • Hasbro Children's Hospital
    • The Miriam Hospital
    • Newport Hospital
    • Bradley Hospital

Deductibles

In-network

Individual

$4,650

Family

$9,300

Out-of-Pocket Limits

In-network

Individual

$5,650

Family

$11,300


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)

$25

PCP not affiliated with a PCMH

$45

Telemedicine

$40

Retail Clinic

$50

Specialist Visit

$60

Urgent Care Center

$75

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)

$7

Tier 2 (Non-preferred Generic)

$35

Tier 3 (Preferred Brand)

$50 after deductible

Tier 4 (Non-Preferred Brand)

$75 after deductible

Tier 5 (Specialty)

$100 after deductible