BlueCHiP for Medicare Value (HMO-POS)

Medicare Plan Details (2023 Plan)


Monthly Premium

 

by Blue Cross Blue Shield of Rhode Island
Additional Coverage
HearingVisionDental
Overall Government Star Rating
 5.0
out of 5 stars

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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

 

$0
$0
$0
$0
$5,000 In-network
$5,000 Out-of-network
No
Yes
Yes
Yes

Doctor Services

In-network: $0-30 copay per visit
Out-of-network: 20% coinsurance per visit
In-network: $30 copay per visit
Out-of-network: 20% coinsurance per visit

Tests, labs, & imaging

In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $150 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance
$90 copay per visit (always covered)
$60 copay per visit (always covered)

Hospital Services

In-network: $375 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-network: 20% per day for days 1 through 90
In-network: $250 copay per visit
Out-of-network: 20% coinsurance per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$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

In-network: $0 copay
Out-of-network: 20% coinsurance

Ambulance

In-network: $150 copay
Out-of-network: $150 copay

Therapy services

In-network: $35 copay
Out-of-network: 20% coinsurance
In-network: $35 copay
Out-of-network: 20% coinsurance

Mental health services

In-network: $35 copay
Out-of-network: 20% coinsurance
In-network: $35 copay
Out-of-network: 20% coinsurance
In-network: $35 copay
Out-of-network: 20% coinsurance
In-network: $35 copay
Out-of-network: 20% coinsurance

Opioid treatment services

Covered

Other services

In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
In-network: $0 copay per item
Out-of-network: 20% coinsurance per item

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseGap coverage phaseCatastrophic coverage phase
Preferred Generic$8.00 copay


Generic drugs :
25%

Brand-name drugs :
25%


Generic drugs :
$4.15 copay or 5% (whichever costs more)

Brand-name drugs :
$10.35 copay or 5% (whichever costs more)

Generic$16.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug$100.00 copay
Specialty Tier33%

Part B Drugs

In-network: 20% coinsurance
Out-of-network: 20% coinsurance
In-network: 20% coinsurance
Out-of-network: 20% coinsurance

Hearing

In-network: $30 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $200-1,675 copay
Out-of-network: No Data

Preventive Dental

In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data

Comprehensive dental

In-network: 50% coinsurance
Out-of-network: No Data
Not covered
In-network: 50% coinsurance
Out-of-network: No Data
Not covered
Not covered
In-network: 50% coinsurance
Out-of-network: No Data
In-network: 50% coinsurance
Out-of-network: No Data

Vision

In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
In-network: $0 copay
Out-of-network: No Data
Not covered

Other benefits

Limited coverage
Limited coverage
Limited coverage
Not covered
Limited coverage
Limited coverage
Limited coverage
 4.5
 5
 4
 4
 5
 5
 4.5
 5
 4
 4
 5

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