Providence Medicare Prime + RX (HMO-POS)

Call us for more information or enroll online.
1-800-457-6064 (TTY: 711)
8 a.m. to 8 p.m. (Pacific time),
Seven days a week (Oct. 1-Feb. 14)
Monday through Friday (Feb. 15-Sept. 30)

Enroll online

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2018 premium and benefit information

Providence Medicare Prime + RX (HMO-POS) 
Monthly premium without prescription drug coverage   N/A
Monthly premium with prescription drug coverage $0

In-Network Out-of-Network
Deductible $0
Benefits You Pay
Out-of-pocket maximum $5,500  $10,000 combined
Doctor office visit (PCP) $5 40%°
Specialist visit $50°
40% no referral
40%° 
Secure video visits $0° No coverage
Preventive care $0° 40%°
Lab $15 40%
X-ray $15 40%
Outpatient diagnostic tests & procedures  20% 40%
Outpatient diagnostic & therapeutic radiology
20% 40%
Durable medical equipment 20% 40%
Diabetic supplies $0 / 20%** 40%
Outpatient surgery Outpatient hospital: $480
Ambulatory surgical center: $275
40%
Inpatient hospital Days 1-4: $440/day
Days 5-90: $0
40%
Skilled nursing facility Days 1-20: $0
Days 21-100: $167.50/day
40%
Home health $0 40%
Mental health & chemical dependency counseling $40 40%
Therapy: PT, OT, ST $40 40%
Medical eye exam $50°
 40%°
Worldwide Coverage ($50,000 Limit)  
Urgent care* $65†  $65†
Emergency room* $80†
$80†
Ambulance (air/ground) $250 one way  $250 one way

* Diagnostic testing copayment may apply.
** Diabetic therapeutic shoes and inserts
° 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 Prime + RX.

Benefit Description Copay
Routine eye exams
  • Focuses on your eyes and overall wellness
  • One exam every calendar year
  • Up to a $40 allowance
$0
Prescription eyeglasses
(lenses, frames, upgrades)
$75 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) $75 allowance per year for prescription contacts $0

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 $3,750, 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* $260
Waived on generic tiers

One-Month Supply
Preferred Network Pharmacy Network Pharmacy
1 - Preferred generic $8 $16
2 - Generic $18 $20
3 - Preferred brand $47
4 - Non-preferred drugs $100
5 - Specialty drugs 27%

Three-Month Supply
Preferred Network Pharmacy Network Pharmacy
1 - Preferred generic $19.20 $48
2 - Generic $43.20 $60
3 - Preferred brand $112.80 $141
4 - Non-preferred drugs $240 $300
5 - Specialty drugs Available on one-month supplies only

*Deductible is waived on all generic tiers (Tiers 1 and 2)


Providence Medicare Prime + RX (HMO-POS) is available in Clackamas, Multnomah and Washington counties in Oregon.

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.