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)

Medicare Advantage Plan for Rhode Island

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PARTCRX

Plan Summary

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderBlue Cross Blue Shield of Rhode Island
Plan IDH4152-18-0
CMS Rating1
Plan TypeHMO-POS
Annual Deductible$200.00

What To Know About This Plan

  • This plan has health and drug coverage

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)

Plan Details

Costs and Other Important Information

Plan Year:
2018
Optional Supplemental Benefits
Yes
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

Service
Cost
Inpatient hospital coverage
In-Network:
$275 for days 1 through 5
$0 for days 6 through 90
Out-of-Network:
20% per stay
Outpatient hospital coverage
In-Network:
20% per visit
Out-of-Network:
20% per visit
Doctor visits
Primary:
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 care
In-Network:
$0 copay
Out-of-Network:
20%
Emergency care/Urgent care
Emergency:
$75 per visit (always covered)
Urgent care:
$55 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic 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 services
In-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 Facility
In-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 services
Occupational therapy visit:
In-Network:
$35
Out-of-Network:
20%
Physical therapy and speech and language therapy visit:
In-Network:
$35
Out-of-Network:
20%
Ambulance
In-Network:
$150
Out-of-Network:
$150
Transportation
Not 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/supplies
Durable 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 drugs
Chemotherapy:
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

Cost Sharing Information

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
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

CMS Ratings

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 management
Not Rated
Care for older adults – medication review
Not Rated
Care for older adults – functional status assessment
Not Rated
Care for older adults – Pain screening
Not 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

Physician Finder

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

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KHATIB, PERVEZ
100 CURTIS ST
PROVIDENCE, RI 02909
SALAK, JESSICA
100 CURTIS ST
PROVIDENCE, RI 02909
BASSEN, DAISY
340 BROADWAY
PROVIDENCE, RI 02909
VANDYCK, WALTER
SPRINGFIELD MIDDLE SCHOOL, PROVIDENE SCHOOL DEPARTMENT
PROVIDENCE, RI 02909
MASTROSTEFANO, PASQUALE
347 BROADWAY
PROVIDENCE, RI 02909
NG, KAREN
100 CURTIS ST
PROVIDENCE, RI 02909
GURNEY, ELLEN
239 CRANSTON ST.
PROVIDENCE, RI 02907
CECE, JOHN
230 RESERVOIR AVE
PROVIDENCE, RI 02907
CLARK-MEDYESY, MELANIE
176 CONGRESS AVE
PROVIDENCE, RI 02907
MUKAND, JON
21 PEACE ST
PROVIDENCE, RI 02907
ABEJUELA, MARIE
21 PEACE ST
PROVIDENCE, RI 02907
SKURKOVICH, BORIS
239 CRANSTON ST
PROVIDENCE, RI 02907
STUTZ, STANLEY
21 PEACE ST
PROVIDENCE, RI 02907
THOMAS, LONICE
100 CURTIS ST
PROVIDENCE, RI 02909
TAMAN, MAGED
21 PEACE STREET
PROVIDENCE, RI 02907
RODRIGUEZ-PERIS, EMILIO
655 BROAD STREET
PROVIDENCE, RI 02907
SCOTT, WALTER
655 BROAD ST
PROVIDENCE, RI 02907
BURKE, ROBERT
239 CRANSTON ST
PROVIDENCE, RI 02907
GREENSPAN, NEIL
44 W RIVER ST
PROVIDENCE, RI 02904
MALIK, TARIQ
530 N MAIN ST
PROVIDENCE, RI 02904
PIZZARELLO, PETER
868 ADMIRAL ST
PROVIDENCE, RI 02904
WEISBLATT, STEVEN
200 HIGH SERVICE AVENUE
NORTH PROVIDENCE, RI 02904
LAM, LAI-YET
146 W RIVER ST FL 3
PROVIDENCE, RI 02904
KORR, KENNETH
208 COLLYER ST
PROVIDENCE, RI 02904
Details
PERVEZ KHATIB, MD
Phone Number
(401) 444-0540
Office Locations
100 CURTIS ST
PROVIDENCE, RI 02909
100 CURTIS ST PROVIDENCE RI, 02909

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