* Diagnostic testing copayment may apply.
° For office visits, other charges may apply.
† Copayment is waived if admitted within 24 hours for the same condition.
Available at no extra charge to members of Providence Medicare Latitude + RX (HMO-POS)
| Benefit |
Description |
Copay |
| Routine eye exams |
- Focuses on your eyes and overall wellness
- One exam every calendar year
- Up to a $60 allowance
|
$0 |
Prescription eyeglasses
(lenses, frames, upgrades) |
$300 allowance per year for any combination of prescription lenses, frames or upgrades (such as tinting)
|
$0
|
| Contact lenses, in lieu of glasses (includes lenses, fitting and evaluation services) |
$300 allowance per year for prescription contacts |
$0 |
Available at no extra charge to members of Providence Medicare Latitude + RX (HMO-POS)
| Benefit |
Description |
Copay |
| Routine hearing exams |
- Covers one routine hearing exam per calendar year
- You must see a TruHearing provider
|
$45 |
| Hearing aids |
- Up to two TruHearing Flyte hearing aids
- every calendar year
- Benefit is limited to TruHearing Flyte Advanced and Flyte Premium hearing aids
- You must see a TruHearing provider
|
$699 or $999 per hearing aid
|
Hearing aid purchase includes three provider visits within the first year of hearing aid purchase. Costs associated with excluded items are the responsibility of the member and not covered by the plan.
How it works
| Initial Coverage |
Coverage Gap |
Catastrophic Coverage |
| Phase 1 |
Phase 2 |
Phase 3 |
When the total paid by you and the plan reaches $3,750, Phase 2 begins.
|
You pay only 35% of the costs of brand-name drugs and 44% of the costs of generic drugs. You stay in this stage until your out-of-pocket costs reach $5,000. After that, Phase 3 begins.
|
You pay whichever of these is
larger: either 5% coinsurance
for the cost of the drug or $3.35 copay for generic drugs, $8.35 copay for brand-name
or specialty drugs. |
What you pay in Phase 1
| Prescription Drug Coverage |
| Annual deductible |
$0
|
|
One-Month Supply |
| Preferred Network Pharmacy |
Network Pharmacy |
| 1 - Preferred generic |
$4 |
$10
|
| 2 - Generic |
$12 |
$20 |
| 3 - Preferred brand |
$45
|
| 4 - Non-preferred drugs |
25%
|
| 5 - Specialty drugs |
33%
|
|
Three-Month Supply |
| Preferred Network Pharmacy |
Network Pharmacy |
| 1 - Preferred generic |
$9.60 |
$30
|
| 2 - Generic |
$28.80 |
$60 |
| 3 - Preferred brand |
$108 |
$135 |
| 4 - Non-preferred drugs |
25%
|
| 5 - Specialty drugs |
Available in one-month supplies only |
Providence Medicare Latitude + Rx (HMO-POS) is available in Crook, Deschutes, Hood River, Jefferson and Wheeler counties.
Does not include any Part B premium you may have to pay. You must continue to pay your Medicare Part B premium.
It may cost more to get care from out-of-network providers except in an emergency or urgent care situation.
Multi-language insert (PDF)
We have free interpreter services to answer any questions you may have about our health or drug plan.
Find out if you qualify for extra help with your premiums ›
Medical appeals, determination and grievance processes ›
For more information about Providence Medicare Advantage Plans, please contact the sales team.
This information is available in a different format, including audio CDs. If you need plan information in another format, please call Customer Service at 503-574-8000 or 1-800-603-2340 (TTY: 711). Service is available between 8 a.m. and 8 p.m. (Pacific time), seven days a week.
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and premiums may change on January 1 of each year. The formulary, pharmacy network, and provider network may change at any time. You will receive notice when necessary.