BlueCHiP for Medicare Extra (HMO-POS) H4152-018-0 Plan Details
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*CMS rated this Blue Cross & Blue Shield of Rhode Island plan (H4152-018-0) 4.5 (Good+) out of 5 stars.
BlueCHiP for Medicare Extra (HMO-POS) is a Medicare Advantage plan with a prescription drug plan. The 2025 Annual Enrollment period starts October 15. Plan benefits begin January
BlueCHiP for Medicare Extra Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | H4152-018-0 |
| Plan Type: | HMO-POS |
| Plan Year: | 2025 |
| Premium: | $111.00/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 4,500.00 /yr (in-network) |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Enhanced, $0.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | See List |
| Insured By: | Blue Cross & Blue Shield of Rhode Island |
| Summary of Benefits |
|---|
Blue Cross & Blue Shield of Rhode Island Out-of-Pocket Costs
This Blue Cross & Blue Shield of Rhode Island Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H4152-018-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | Not Covered |
| Specialist: | $25 Copay Referral Required |
Emergency, Urgent, and Inpatient Hospital Coverage
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $100 Copay |
| Urgent care: | $30 Copay |
| Ground ambulance: | $175 Copay |
| Inpatient hospital care: | $275.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $214.00 per day for days 21 through 45 $0.00 per day for days 46 and beyond |
Foot Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $25 Copay Referral Required |
| Routine Foot Care: | $25 Copay Referral Required |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $20 Copay Referral Required |
| Routine chiropractic: | Not Covered |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $25 Copay |
| Outpatient group therapy: | $25 Copay |
| Inpatient psychiatric hospital care: | $275.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Rehabilitation Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $25 Copay Prior Authorization Required |
| Occupational therapy: | $25 Copay Prior Authorization Required |
Medical Equipment and Supplies
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | Not Covered |
| Durable medical equipment: | 10% Coinsurance Prior Authorization Required |
| Prosthetics: | 10% Coinsurance |
Diagnostics, Lab Services, and Imaging
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $100 Copay Prior Authorization Required |
| Lab services: | Not Covered |
| Outpatient x-rays: | Not Covered |
| Diagnostic tests and procedures: | Not Covered |
Medicare Part B Drugs
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
Dental Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | 20% Coinsurance |
| Oral exam | $0 |
| Dental x-rays | $0 |
| Cleaning | $0 |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
| Maximum dental benefit: | $2,500.00 (Every year) |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Not Covered |
| Hearing exam | Covered Limits may apply |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam | $ to $25 Copay |
| Routine eye exam | Covered Limits may apply |
| Eyewear benefits | None |
Feel free to download our BlueCHiP for Medicare Extra Summary of Benefits information.
Prescription Drug Costs & Benefits
BlueCHiP for Medicare Extra includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans offer greater coverage than basic plans, typically providing lower cost-sharing, broader drug coverage, and additional benefits, such as covering drugs not included in the standard formulary. These plans usually have higher premiums due to the extra coverage and flexibility they provide, but they cover a larger percentage of overall drug costs.
As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.
Part D Prescription Drug Premium
The table below outlines the Part D premium costs for this Blue Cross & Blue Shield of Rhode Island plan, showing the monthly portion of the total premium dedicated to prescription drug coverage. While the Part D premium is included in the overall plan cost, some plans may have supplemental charges or offer assistance through the Low-Income Subsidy (LIS) program. Also known as Extra Help, LIS is a Social Security initiative that helps individuals with limited income and resources reduce or eliminate Part D expenses.
| Basic Part D Premium: | $2.90 |
| Supplemental Part D Premium: | $55.20 |
| Total Part D Premium: | $58.10 |
| Low Income Premium Subsidy: | $52.52 |
| Low Income Premium Subsidy CMS Pays: | $2.90 |
| Low Income Subsidy Premium: | $55.20 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $0.00. You must pay this amount at the pharmacy before Blue Cross & Blue Shield of Rhode Island begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, BlueCHiP for Medicare Extra has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order | |
|---|---|---|---|
| Preferred Generic | $0.00 | $0.00 | |
| Generic | $0.00 | $0.00 | |
| Preferred Brand | $47.00 | $0.00 | |
| Non-Preferred Drug | $100.00 | $0.00 | |
| Specialty Tier | 33.00% | 33.00% | |
| *The Part D deductible does not apply. | |||
CMS 5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories using a 5-star rating system. Here are the most recent CMS ratings for BlueCHiP for Medicare Extra .
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Plan Availability
BlueCHiP for Medicare Extra (H4152-018-0) is available in the following locations (click to open):
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
- H4152-005-0: BlueCHiP for Medicare Plus (HMO)
- H4152-020-0: BlueCHiP for Medicare Value (HMO-POS)
- H4152-007-0: BlueCHiP for Medicare Preferred (HMO-POS)
- H4152-013-0: BlueCHiP for Medicare Enhanced (HMO-POS)
- H4152-022-0: BlueCHiP for Medicare Access (HMO-POS)
- H4152-018-0: BlueCHiP for Medicare Extra (HMO-POS)
- H4152-004-0: BlueCHiP for Medicare Core (HMO)
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact Blue Cross & Blue Shield of Rhode Island
| Website: | Blue Cross & Blue Shield of Rhode Island Plan Page |
|---|---|
| Providers: | Blue Cross & Blue Shield of Rhode Island Providers Page |
| Formulary: | Blue Cross & Blue Shield of Rhode Island Formulary Page |
| Pharmacy: | Blue Cross & Blue Shield of Rhode Island Pharmacy Page |
| New Member Health Plan Help: | (800)505-2583 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (800)505-2583 |
| New Member Part D TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- Blue Cross & Blue Shield of Rhode Island, http://www.BCBSRI.com/Medicare, Last Accessed February 20, 2024
- Medicare.gov, "Medicare Advantage Plans cover all Medicare services", Last Accessed February 20, 2024
- Medicare.gov, "How Original Medicare Works", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.