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After meeting the deductible, the member pays the following amounts for covered services. The deductible does not apply to some covered services. The are marked with †.
|
Providence
Preventive |
Providence
Essential |
Providence
Essential Access |
Providence
Advantage Access |
Coverage Type
|
In-network |
Out-of-network
|
In-network
|
Out-of-network
|
In-network
|
Out-of-network
|
In-network
|
Out-of-network
|
Network |
Providence |
All other providers |
Providence |
All other providers |
Providence |
All other providers |
Providence |
All other providers |
Deductible |
None |
$50 |
$50 |
$25 |
Annual maximum |
None |
$1,000 |
$1,000 |
$1,500 |
Waiting period |
None |
None |
None |
None |
Diagnostic and preventive services1 |
Covered in full† |
Covered in full† |
Covered in full† |
10%† |
Covered in full† |
10%† |
Covered in full† |
Covered in full† |
Basic services2 |
N/A |
20% |
30% |
20% |
30% |
20% |
20% |
Major services3 |
N/A |
50% |
60% |
50% |
50% |
50% |
50% |
Out-of-network** |
MAC* |
--- |
UCR 90th percentile |
UCR 90th percentile |
2018 Rates |
Subscriber only |
$9.27 |
$26.39 |
$31.60 |
$35.16 |
Subscriber and spouse |
$18.35 |
$52.78 |
$63.21 |
$70.32 |
Subscriber and child(ren) |
$18.82 |
$46.18 |
$55.31 |
$61.53 |
Subscriber, spouse and child(ren) |
$27.81 |
$75.21 |
$90.07 |
$100.21 |
Orthodontics/orthodontia are not available.
*Maximum allowable charge by the provider
**Balance billing may apply for out-of-network services
1Includes routine exams, cleanings, bitewing X-rays, topical fluoride (age 16 and younger), space maintainers
2Includes restorative fillings, oral surgery, endodontics, periodontics
3Includes crowns, dentures, bridge work