2021 Medicare Advantage Plan Details | |||||
---|---|---|---|---|---|
Medicare Plan Name: | BlueCHiP for Medicare Plus (HMO) | ||||
Location: | Washington, Rhode Island Click to see other locations | ||||
Plan ID: | H4152 - 005 - 0 Click to see other plans | ||||
Member Services: | 1-401-277-2958 TTY users 711 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
||||
Email a copy of the BlueCHiP for Medicare Plus (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $161.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $0 | ||||
Annual Rx Initial Coverage Limit (ICL): | $4,130 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $2,800 | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,494 drugs | Browse the BlueCHiP for Medicare Plus (HMO) Formulary | |||
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||
This plan offers select insulin at a $35 copay. Learn more. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $3.00 | $6.00 | $47.00 | $100.00 | 33% |
• Number of Drugs per Tier: | 322 | 967 | 933 | 551 | 721 |
Plan's Pharmacy Search: | http://www.BCBSRI.com/Medicare | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in Washington, Rhode Island: | 216 members | ||||
Number of Members enrolled in this plan in Rhode Island: | 2,340 members | ||||
Number of Members enrolled in this plan in (H4152 - 005): | 2,357 members | ||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 3 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 5 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Basic Premium | Part D Supplemental Premium | |
$161.00 | $147.40 | $13.60 | $0.00 | ||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $3.40 | $6.80 | $10.20 | |
Total Monthly Premium with LIS (Parts C & D): | $147.40 | $150.80 | $154.20 | $157.60 |
— Plan Health Benefits — | |||||
** Base Plan ** | |||||
Premium | |||||
• Total monthly premium: $161.00 | |||||
• Health plan premium: $147.40 | |||||
• Drug plan premium: $13.60 | |||||
• You must continue to pay your Part B premium. | |||||
• Part B premium reduction: No | |||||
Deductible | |||||
• Health plan deductible: $0 | |||||
• Other health plan deductibles: In-network: No | |||||
• Drug plan deductible: No annual deductible | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $2,800 In-network | |||||
Optional supplemental benefits | |||||
• No | |||||
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? | |||||
• In-network: No | |||||
Doctor visits | |||||
• Primary: $0-5 copay per visit | |||||
• Specialist: $25 copay per visit (referral required) | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: $0 copay (authorization required) | |||||
• Lab services: $0 copay (authorization required) | |||||
• Diagnostic radiology services (e.g., MRI): $150 copay (authorization required) | |||||
• Outpatient x-rays: $0 copay (authorization required) | |||||
Emergency care/Urgent care | |||||
• Emergency: $75 copay per visit (always covered) | |||||
• Urgent care: $50 copay per visit (always covered) | |||||
Inpatient hospital coverage | |||||
• $190 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) | |||||
Outpatient hospital coverage | |||||
• $150 copay per visit (authorization required) | |||||
Skilled Nursing Facility | |||||
• $0 per day for days 1 through 20 $135 per day for days 21 through 45 $0 per day for days 46 through 100 (authorization required) | |||||
Preventive care | |||||
• $0 copay | |||||
Ground ambulance | |||||
• $75 copay | |||||
Rehabilitation services | |||||
• Occupational therapy visit: $15 copay (referral required) | |||||
• Physical therapy and speech and language therapy visit: $15 copay (referral required) | |||||
Mental health services | |||||
• Inpatient hospital - psychiatric: $190 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) | |||||
• Outpatient group therapy visit with a psychiatrist: $25 copay (authorization required) | |||||
• Outpatient individual therapy visit with a psychiatrist: $25 copay (authorization required) | |||||
• Outpatient group therapy visit: $25 copay (authorization required) | |||||
• Outpatient individual therapy visit: $25 copay (authorization required) | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): 20% coinsurance per item (authorization required) | |||||
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required) | |||||
• Diabetes supplies: $0 copay per item (authorization required) | |||||
Hearing | |||||
• Hearing exam: $25 copay | |||||
• Fitting/evaluation: $0 copay (limits apply) | |||||
• Hearing aids: $0 copay (limits apply) | |||||
Preventive dental | |||||
• Oral exam: $0 copay (limits apply, authorization required) | |||||
• Cleaning: $0 copay (limits apply, authorization required) | |||||
• Fluoride treatment: Not covered | |||||
• Dental x-ray(s): $0 copay (limits apply, authorization required) | |||||
Comprehensive dental | |||||
• Non-routine services: $0 copay (limits apply, authorization required) | |||||
• Diagnostic services: Not covered | |||||
• Restorative services: $0 copay (limits apply, authorization required) | |||||
• Endodontics: $0 copay (limits apply, authorization required) | |||||
• Periodontics: Not covered | |||||
• Extractions: $0 copay (limits apply, authorization required) | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: $0 copay (limits apply, authorization required) | |||||
Vision | |||||
• Routine eye exam: $0 copay (limits apply) | |||||
• Other: Not covered | |||||
• Contact lenses: $0 copay (limits apply) | |||||
• Eyeglasses (frames and lenses): $0 copay (limits apply) | |||||
• Eyeglass frames: $0 copay (limits apply) | |||||
• Eyeglass lenses: $0 copay (limits apply) | |||||
• Upgrades: Not covered | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered (authorization required) | |||||
Transportation | |||||
• $0 copay (limits apply) | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: $25 copay (referral required) | |||||
• Routine foot care: $25 copay (referral required) | |||||
Medicare Part B drugs | |||||
• Chemotherapy: 20% coinsurance (authorization required) | |||||
• Other Part B drugs: 20% coinsurance (authorization required) |