BlueRI for Duals (HMO D-SNP)

Medicare Plan Details (2022 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
$3,450 In-network
No
Yes
Yes
Yes

Doctor Services

$0 copay
$0 copay

Tests, labs, & imaging

$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay

Hospital Services

$0 copay
$0 copay

Skilled nursing facility

$0 copay

Preventive services

$0 copay

Ambulance

$0 copay

Therapy services

$0 copay
$0 copay

Mental health services

$0 copay
$0 copay
$0 copay
$0 copay

Opioid treatment services

Covered

Other services

$0 copay
$0 copay
$0 copay

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

TiersInitial coverage phaseGap coverage phase1Catastrophic coverage phase
Preferred Generic$0.00 copay$0.00 copay


Generic drugs :
$3.95 copay or 5% (whichever costs more)

Brand-name drugs :
$9.85 copay or 5% (whichever costs more)

Generic$0.00 copay$0.00 copay
Preferred Brand25%
Non-Preferred Drug25%
Specialty Tier25%
1 For all other drugs, you pay 25% for generic drugs and 25% for brand-name drugs.

Part B Drugs

$0 copay
$0 copay

Hearing

$0 copay
$0 copay
$0 copay

Preventive Dental

$0 copay
$0 copay
Not covered
$0 copay

Comprehensive dental

$0 copay
Not covered
$0 copay
$0 copay
Not covered
$0 copay
$0 copay

Vision

$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
Not covered

Other benefits

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

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