Providence Medicare Latitude + RX (HMO-POS)

Call us for more information:
1-888-226-7338 (TTY: 711)
8 a.m. to 8 p.m. (Pacific time),
Seven days a week (Oct. 1-Mar. 31)
Monday through Friday (Apr. 1-Sept. 30)

Enroll online

Find a provider or pharmacy ›

2019 premium and benefit information

Providence Medicare Latitude + RX (HMO-POS)
Monthly premium with prescription drug coverage
 $195

In-Network Out-of-Network
Medical deductible $0
Benefits You Pay
Out-of-pocket maximum $5,500 $5,500 combined 
Doctor office visit (PCP) $15° 30%°
Specialist visit $40°
30% no referral°
 30%°
Secure video visits $0°  No coverage
Preventive care $0° 30%°
Lab $10 30%
X-ray $15 30%
Outpatient diagnostic tests & procedures  20% 30%
Outpatient diagnostic & therapeutic radiology
 20% 30%
Durable medical equipment 20% 30%
Diabetic supplies $0 30%
Outpatient surgery $250 30%
Inpatient hospital Days 1-5: $275/day
Days 6 & beyond: $0		 30%
Skilled nursing facility Days 1-20: $0
Days 21-100: $150/day		 30%
Home health $0 30%
Mental health & chemical dependency counseling $40 30%
Therapy: PT, OT, ST $40 30%
Medical eye exam $40°
 30%
Worldwide Coverage ($50,000 Limit)  
Urgent care* $50† $50† 
Emergency room* $90†
 $90† 
Ambulance (air/ground) $200 one way $200 one way

* Diagnostic testing copayment may apply.
° For office visits, other charges may apply.
† Copayment is waived if admitted within 24 hours for the same condition.

Vision coverage

Available at no extra charge to members of Providence Medicare Latitude + RX (HMO-POS)

Benefit Description
Routine eye exams
  • Focuses on your eyes and overall wellness
  • One exam every calendar year
  • Up to a $60 allowance
Prescription eyeglasses (lenses, frames, upgrades) or contact lenses (including fitting and evaluation services)
 $250 allowance per year for any combination of prescription lenses, frames or upgrades (such as tinting) or contact lenses

Hearing coverage

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 hearing aids every calendar year
  • Benefit is limited to TruHearing Advanced and 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.

Pharmacy coverage – Part D

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 $3,820, Phase 2 begins.
 You pay only 25% of the costs of brand-name drugs and 37% of the costs of generic drugs. You stay in this stage until your out-of-pocket costs reach $5,100. After that, Phase 3 begins.
 You pay whichever of these is larger: either 5% coinsurance for the cost of the drug or $3.40 copay for generic drugs, $8.50 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 $10 $20
3 - Preferred brand $47
4 - Non-preferred drugs $90
 $100 
5 - Specialty drugs 33%

Three-Month Supply
Preferred Network Pharmacy Network Pharmacy
1 - Preferred generic $9.60 $30
2 - Generic $24 $60
3 - Preferred brand $112.80 $141
4 - Non-preferred drugs $216
 $300
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.

Out-of-network/noncontracted providers are under no obligation to treat Providence Medicare Advantage Plan members, except in emergency situations. Please call customer service or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

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.

Non-discrimination notice (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. Call 1-800-603-2340 TTY: 711 for more information.