2014 Plan Comparison


Contact us

Customer Service
503-574-8000 or
800-603-2340
M-Sun, 8 a.m. to 8 p.m.

Medicare Advantage Sales
503-574-5551 or
800-457-6064

TTY: 711
M-Sun, 8 a.m. to 8 p.m.

Mailing Address

At Providence Health Plans, we're part of a family of doctors, clinics and hospitals that bring you an exceptional level of service and care. Whether it's your spouse, friend or neighbor, chances are someone you know has been touched by Providence's unique brand of caring. At Providence, it's not just health care, it's how we care.

Monthly Premium

Providence Medicare Choice (HMO-POS) Providence Medicare Choice + RX (HMO-POS) * Providence Medicare Extra (HMO) Providence Medicare Extra + RX (HMO) *
$28 $61 $92 $137
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* The premiums listed are for both medical services and prescription drug benefits.
Note: You must continue to pay your Medicare Part B premium.
Beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances.
Quantity limitations and restrictions may apply.

Medical Benefits

Providence Medicare Extra (HMO) Providence Medicare Choice (HMO-POS)
In-plan In-plan Out-of-plan
No deductible No deductible No deductible
You Pay You Pay You Pay
Out-of-pocket Maximum $2,500 $3,000 $3,900 combined
Doctor Office $15 $20 $30
Specialist Visit $20 $30
$40 no referral
$40
Lab $0 $0 20%
X-ray 15% 20% 20%
Skilled nursing facility Days 1-20: $50
Days 21-100: $100
Days 1-20: $50
Days 21-100: $100
Days 1-100: 20%
Outpatient surgery $150 $250 20%
Home health $0 15% 20%
Durable medical equipment 20% 20% 20%
Test strips and glucometers $0 $0 20%
Medical eye exam $20 $30 $40
Routine eye exam $15 $20 $20
Covered up to $45
Vision hardware $100 every two years $100 every two years $100 every two years
Inpatient hospital Days 1-7: $200
Days 8 and beyond: $0
Days 1-7: $250
Days 8 and beyond: $0
20%
Urgent care* $20 $30 $30
Emergency room $65 $65 $65
Ambulance
(air/ground)
$100
One way
$150
One way
$150
One way
Mental health and chemical dependency counseling $20 $30 20%
Therapy: PT, OT, ST $20 $30 20%

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

Part D – How it works

Initial Coverage
Phase 1
Coverage Gap
Phase 2
Catastrophic Coverage
Phase 3
When the total paid by you and the plan reaches $2,850, Phase 2 begins. You pay only 47.5% of the costs of brand name drugs and 72% of the costs of generic drugs.

You stay in this stage until your out-of-pocket costs reach $4,550.

After that Phase 3 begins.
You pay whichever of these is larger: either 5% coinsurance for the cost of the drug or $2.55 copay for generic drugs, $6.35 copay for brand name or specialty drugs.

What you pay in Phase 1

Drug Tier Preferred Network Pharmacy Network Pharmacy
Preferred Generic $6 $9
Non-Preferred Generic $11 $20
Preferred Brand $45 $45
Non-Preferred Brand $95 $95
Injectable Meds 33% 33%
Specialty Meds 33% 33%

You must continue to pay your Medicare Part B Premium.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/co-insurance may change on January 1 of each year.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778 or your state Medicaid office.

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