2018 BlueCHiP for Medicare Extra (HMO-POS) H4152-18-0 in RI from Blue Cross Blue Shield of Rhode Island | HealthPocket

BlueCHiP for Medicare Extra (HMO-POS)

$1,164/mo

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Zip Code02909
Applicant10/22/1983 Male
Coverage Start10/24/2018
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Benefits & Coverage

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderBlue Cross Blue Shield of Rhode Island
Plan IDH4152-18-0
Plan Year2018
CMS Rating
Plan TypeHMO-POS
Annual Deductible$200.00

What To Know About This Plan
  • This plan has health and drug coverage
  • This plan is available for 2019. see plan

Why We Like This Plan
  • has both Health and Drug Coverage
  • has a copay of $0 for Tier 1 preferred generic drugs (30 day supply, preferred retail pharmacies)

Costs and Other Important Information

Plan Year2018
Optional Supplemental BenefitsYes
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$3,750 In-network $10,000 Out-of-network
Other health plan deductibles?No
Health Plan Deductible$0
Monthly Drug Plan Premium$66.40
Monthly Health Plan Premium$30.60

Benefits

SERVICECOST
Inpatient hospital coverageIn-Network:
$275 for days 1 through 5
$0 for days 6 through 90
Out-of-Network:
20% per stay
Outpatient hospital coverageIn-Network:
20% per visit
Out-of-Network:
20% per visit
Doctor visitsPrimary:
In-Network:
$0-10 per visit
Out-of-Network:
20% per visit
Specialist:
In-Network:
$35 per visit
Out-of-Network:
20% per visit
Preventive careIn-Network:
$0 copay
Out-of-Network:
20%
Emergency care/Urgent careEmergency:
$75 per visit (always covered)
Urgent care:
$55 per visit (always covered)
Diagnostic procedures/lab services/imagingDiagnostic tests and procedures:
In-Network:
$10
Out-of-Network:
20%
Lab services:
In-Network:
$10
Out-of-Network:
20%
Diagnostic radiology services (e.g., MRI):
In-Network:
$200
Out-of-Network:
20%
Outpatient x-rays:
In-Network:
$10
Out-of-Network:
20%
Mental health servicesIn-Network:
$275 for days 1 through 4
$0 for days 5 through 90
Out-of-Network:
20% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network:
$35
Out-of-Network:
20%
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$35
Out-of-Network:
20%
Outpatient group therapy visit:
In-Network:
$35
Out-of-Network:
20%
Outpatient individual therapy visit:
In-Network:
$35
Out-of-Network:
20%
Skilled Nursing FacilityIn-Network:
$0 for days 1 through 20
$150 for days 21 through 45
$0 for days 46 through 100
Out-of-Network:
20% per stay
Rehabilitation servicesOccupational therapy visit:
In-Network:
$35
Out-of-Network:
20%
Physical therapy and speech and language therapy visit:
In-Network:
$35
Out-of-Network:
20%
AmbulanceIn-Network:
$150
Out-of-Network:
$150
TransportationNot covered
Foot care (podiatry services)Foot exams and treatment:
In-Network:
$35
Out-of-Network:
20%
Routine foot care:
In-Network:
$35
Out-of-Network:
20%
Medical equipment/suppliesDurable medical equipment (e.g., wheelchairs, oxygen):
In-Network:
20% per item
Out-of-Network:
20% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
20% per item
Diabetes supplies:
In-Network:
$0 per item
Out-of-Network:
20% per item
Wellness programs (e.g., fitness, nursing hotline)Covered
Medicare Part B drugsChemotherapy:
In-Network:
20%
Out-of-Network:
20%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
20%

Coverage Area for BlueCHiP for Medicare Extra (HMO-POS)

StateRhode Island
CountyProvidence

All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit


30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$8 copayNot offered
Tier 2: Non-Preferred Generic$5 copay$13 copayNot offered
Tier 3: Preferred Brand Name$47 copay$47 copayNot offered
Tier 4: Non-Preferred Brand Name$100 copay$100 copayNot offered
Tier 5: Specialty Tier29% coinsurance29% coinsuranceNot offered

60 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$16 copayNot offered
Tier 2: Non-Preferred Generic$10 copay$26 copayNot offered
Tier 3: Preferred Brand Name$94 copay$94 copayNot offered
Tier 4: Non-Preferred Brand Name$200 copay$200 copayNot offered
Tier 5: Specialty Tier
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$24 copayNot offered
Tier 2: Non-Preferred Generic$15 copay$39 copayNot offered
Tier 3: Preferred Brand Name$141 copay$141 copayNot offered
Tier 4: Non-Preferred Brand Name$300 copay$300 copayNot offered
Tier 5: Specialty Tier

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Colorectal cancer screening
Annual flu vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Adult BMI assessment

Managing Chronic Conditions

Special needs plan care managementNot Rated
Care for older adults – medication reviewNot Rated
Care for older adults – functional status assessmentNot Rated
Care for older adults – Pain screeningNot Rated
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Controlling blood pressure
Rheumatoid arthritis management
Reducing the risk of falling
Plan all-cause readmissions

Member Experience with Health Plan

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan
Care Coordination

Member Complaints, and Changes in Health Plan's Performance

Complaints about the health plan
Members choosing to leave the health plan
Beneficiary access and performance problems
Health plan quality improvement

Health Plan Customer Service

Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability - Medical

Drug Plan Customer Service

Call center – foreign language interpreter and TTY/TDD availability - Drugs
Appeals auto-forward
Appeals upheld

Member Complaints, and Changes in Drug Plan's Performance

Complaints about the drug plan
Members choosing to leave the drug plan
Beneficiary access and performance problems
Drug plan quality improvement

Member Experience with Drug Plan

Rating of drug plan
Getting needed prescription drugs

Drug Pricing and Patient Safety

MPF Price Accuracy
High risk medication
Part D medication adherence for diabetes
Part D medication adherence for hypertension
Part D medication adherence for cholesterol
Medication Therapy Management program completion rate

Physicians that accept BlueCHiP for Medicare Extra (HMO-POS) for Rhode Island

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Khatib, Pervez
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Soria Galvarro Duran, Erick
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Salak, Jessica
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Vandyck, Walter
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Bassen, Daisy
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Mastrostefano, Pasquale
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Gurney, Ellen
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Skurkovich, Boris
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Stutz, Stanley
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Rodriguez-peris, Emilio
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Taman, Maged
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Scott, Walter
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Solanki, Shalini
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Thomas, Lonice
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Cece, John
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Abejuela, Marie
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Mukand, Jon
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Pervez Khatib, MD
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  • Phone Number
    (401) 444-0540
  • Office Locations
    100 Curtis St
    Providence, RI 02909
100 Curtis St Providence RI, 02909
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