BlueCHiP for Medicare Value (HMO-POS)
Medicare Plan Details (2023 Plan)
Monthly Premium
by Blue Cross Blue Shield of Rhode Island
Additional Coverage
Overall Government Star Rating
5.0Ready to Enroll Online?
Plan Type
Medicare Advantage (Part C) with Prescription Drug (Part D)
Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D
Plan Details
$5,000 Out-of-network
Medical Benefits
Doctor Services
Out-of-network: 20% coinsurance per visit
Out-of-network: 20% coinsurance per visit
Tests, labs, & imaging
Out-of-network: 20% coinsurance
Out-of-network: 20% coinsurance
Out-of-network: 20% coinsurance
Out-of-network: 20% coinsurance
Hospital Services
$0 per day for days 6 through 90
Out-of-network: 20% per day for days 1 through 90
Out-of-network: 20% coinsurance per visit
Skilled nursing facility
$180 per day for days 21 through 45
$0 per day for days 46 through 100
Out-of-network: 20% per day for days 1 through 100
Preventive services
Out-of-network: 20% coinsurance
Ambulance
Out-of-network: $150 copay
Therapy services
Out-of-network: 20% coinsurance
Out-of-network: 20% coinsurance
Mental health services
Out-of-network: 20% coinsurance
Out-of-network: 20% coinsurance
Out-of-network: 20% coinsurance
Out-of-network: 20% coinsurance
Opioid treatment services
Other services
Out-of-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
Prescription Drug Benefits
Tier drug costs for: Standard retail pharmacy drug cost for 1-month
| Tiers | Initial coverage phase | Gap coverage phase | Catastrophic coverage phase |
|---|---|---|---|
| Preferred Generic | $8.00 copay |
Brand-name drugs :
|
Brand-name drugs :
|
| Generic | $16.00 copay | ||
| Preferred Brand | $47.00 copay | ||
| Non-Preferred Drug | $100.00 copay | ||
| Specialty Tier | 33% |
Part B Drugs
Out-of-network: 20% coinsurance
Out-of-network: 20% coinsurance
Extra Benefits
Hearing
Out-of-network: 20% coinsurance
Out-of-network: 20% coinsurance
Out-of-network: No Data
Preventive Dental
Out-of-network: No Data
Out-of-network: No Data
Out-of-network: No Data
Out-of-network: No Data
Comprehensive dental
Out-of-network: No Data
Out-of-network: No Data
Out-of-network: No Data
Out-of-network: No Data
Vision
Out-of-network: 20% coinsurance
Out-of-network: No Data
Out-of-network: No Data
Out-of-network: No Data
Out-of-network: No Data
Other benefits
Health Plan Star Ratings
(government star ratings are out of 5 stars)
Prescription Drug Plan Star Ratings
(government star ratings are out of 5 stars)
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