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BlueCHiP for Medicare Plus (HMO)

H4152 - 005 - 0

(4.5 / 5)

BlueCHiP for Medicare Plus (HMO) is a Medicare Advantage Plan by Blue Cross & Blue Shield of Rhode Island.

This page features plan details for 2025 BlueCHiP for Medicare Plus (HMO) H4152 – 005 – 0.

IMPORTANT: This page features the 2025 version of this plan. See the 2025 version using the link below:

2025 BlueCHiP for Medicare Plus (HMO) H4152 - 005 - 0

Locations

BlueCHiP for Medicare Plus (HMO) is offered in the following locations.

Bristol County, Rhode Island

Kent County, Rhode Island

Newport County, Rhode Island

Click to see more locations

Plan Overview

BlueCHiP for Medicare Plus (HMO) offers the following coverage and cost-sharing.

Insurer:	Blue Cross & Blue Shield of Rhode Island
Health Plan Deductible:	$0
MOOP:	$3,500 In-network
Drugs Covered:	Yes

Ready to sign up for BlueCHiP for Medicare Plus (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

BlueCHiP for Medicare Plus (HMO) has a monthly premium of $120.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$94.50	$25.50	$	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

BlueCHiP for Medicare Plus (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$0.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$25.50	$25.50

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic	$3.00 Copay
2) Generic	$6.00 Copay
3) Preferred Brand	$47.00 Copay
4) Non-Preferred Drug	$100.00 Copay
5) Specialty Tier		33.00% Coinsurance	33.00% Coinsurance

60 Day

Tier	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic	$6.00 Copay		$22.00 Copay
2) Generic	$12.00 Copay		$28.00 Copay
3) Preferred Brand	$94.00 Copay	$94.00 Copay	$94.00 Copay
4) Non-Preferred Drug	$200.00 Copay	$200.00 Copay	$200.00 Copay
5) Specialty Tier

90 Day

Tier	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic	$9.00 Copay		$33.00 Copay
2) Generic	$18.00 Copay		$42.00 Copay
3) Preferred Brand	$141.00 Copay	$117.50 Copay	$141.00 Copay
4) Non-Preferred Drug	$300.00 Copay	$250.00 Copay	$300.00 Copay
5) Specialty Tier

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

BlueCHiP for Medicare Plus (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: No

Comprehensive Dental

Adjunctive General Services
- In-Network: No Coins – No Co pay (Limits Apply)
Endodontics
- In-Network: No Coins – No Co pay (Limits Apply)
Oral and Maxillofacial Surgery
- In-Network: No Coins – No Co pay (Limits Apply)
Periodontics
- In-Network: No Coins – No Co pay (Limits Apply)
Prosthodontics, fixed
- In-Network: No Coins – No Co pay (Limits Apply)
Prosthodontics, removable
- In-Network: No Coins – No Co pay (Limits Apply)
Restorative Services
- In-Network: No Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – No Copay
Fluoride Treatment
- In-Network: No Coins – No Copay
Oral Exams
- In-Network: No Coins – No Copay
Prophylaxis (cleaning)
- In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

Outpatient x-rays
- $0 copay (Authorization Required)
Lab services
- $0 copay (Authorization Required)
Diagnostic radiology services (e.g., MRI)
- $175 copay (Authorization Required)
Diagnostic tests and procedures
- $0 copay (Authorization Required)

Doctor visits

Primary
- $0 copay
Specialist
- $25 copay per visit (Referral Required)

Emergency care/Urgent care

Emergency
- $125 copay per visit (always covered)
Urgent care
- $50 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment
- $25 copay (Referral Required)
Routine foot care
- $25 copay (Referral Required)

Ground ambulance

- $175 copay

Health plan deductible

- $0

Hearing

Hearing aids
- $0-1,475 copay (Limits Apply)
Hearing aids OTC
- Not covered
Fitting/evaluation
- $0 copay (Limits Apply)
Medicare-Covered Hearing Exam
- $25 copay

Inpatient hospital coverage

- $225 per day for days 1 through 5
  $0 per day for days 6 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $3,500 In-network

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
Diabetes supplies
- $0 copay

Medicare Part B drugs

Chemotherapy
- 0-20% coinsurance
Other Part B drugs
- 0-20% coinsurance

Mental health services

Inpatient hospital – psychiatric
- $225 per day for days 1 through 5
  $0 per day for days 6 through 90
  $0 per day for days 91 and beyond
Outpatient group therapy visit
- $25 copay
Outpatient group therapy visit with a psychiatrist
- $25 copay
Outpatient individual therapy visit
- $25 copay
Outpatient individual therapy visit with a psychiatrist
- $25 copay

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $0-200 copay per visit (Authorization Required)

Preventive care

- $0 copay

Rehabilitation services

Physical therapy and speech and language therapy visit
- $15 copay (Authorization Required)
Occupational therapy visit
- $15 copay (Authorization Required)

Skilled Nursing Facility

- $0 per day for days 1 through 20
  $214 per day for days 21 through 45
  $0 per day for days 46 through 100 (Authorization Required)

Transportation

- Not covered

Vision

Contact lenses
- $0 copay (Limits Apply)
Eyeglass frames
- $0 copay (Limits Apply)
Other
- Not covered
Routine eye exam
- $0 copay (Limits Apply)
Eyeglasses (frames and lenses)
- $0 copay (Limits Apply)
Upgrades
- Not covered
Eyeglass lenses
- $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

- Covered