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8 a.m. to 8 p.m. (Pacific time),
Seven days a week (Oct. 1-Mar. 31)
Monday through Friday (Apr. 1-Sept. 30)
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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.
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
|
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.
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.