| Providence ExpressCare Virtual | Covered in full |
| Providence ExpressCare Retail Health Clinic visits | Covered in full |
Plan Details
Connect 1500 Gold
Rating
Overview
|
Annual Deductible |
$1,500/$3,000 |
|
Out-of-Pocket Maximum |
$8,200/$16,400 |
Connect Network
Important note about these benefits
Below you will find the amount you will pay for in-network services after you have met your calendar year deductible.
When you see a (""), the deductible does not apply.
Benefit Summary
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On-Demand Visits
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Preventive Care
Periodic health exams and well-baby care Covered in full
Routine immunizations and shots Covered in full
Colonoscopy (preventive, age 45+) Covered in full
Gynecological exams (1 per calendar year), breast exams and Pap tests Covered in full
Mammograms Covered in full
Nutritional Counseling Covered in full
Tobacco cessation, counseling/classes and deterrent medications Covered in full
Diabetes Self-Management Education Covered in full
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Physician/Professional Services
Office visits to a Primary Care Provider or Naturopath
In-Person
VirtuallyFirst 3 visits $5 then
$30
$10
Office visits to an Alternative Care Provider (In-Person or Virtually)
(Chiropractic manipulation and acupuncture services are covered separately from the office visit at the levels listed for those benefits.)$30
Office visits to specialists (In-Person or Virtually) $50
Inpatient Hospital visits 20%
Allergy shots and allergy serums, injectable and infused medications 20%
Surgery and anesthesia in an office or facility 20%
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Diagnostic Services
X-ray, lab and testing Services (includes ultrasound) 20%
High-tech imaging Services (such as PET, CT or MRI) 20%
Sleep studies 20%
Diagnostic and Supplemental Breast Exams Covered in full
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Emergency Care and Urgent Care Services
Emergency Services
(For Emergency Medical Conditions only. If admitted to the Hospital, all Services subject to inpatient benefits.)
In-Network
Out-of-Network$250 then 20%
$250 then 20%Emergency medical transportation (air and/or ground)
(Emergency transportation is covered regardless of whether or not the provider is an In-Network Provider.)
In-Network
Out-of-Network20%
20%
Urgent Care visits (for non-life threatening illness/minor injury)
In-Network
Out-of-Network$50
$50
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Hospital Services
Inpatient/Observation care 20%
Skilled Nursing Facility (limited to 60 days per calendar year) 20%
Inpatient rehabilitative care
(Limited to 30 days per calendar year; 60 days for head/spinal injuries. Limits do not apply to Mental Health and Substance Use Disorder Services.)20%
Inpatient habilitative care
(Limited to 30 days per calendar year; 60 days for head/spinal injuries. Limits do not apply to Mental Health and Substance Use Disorder Services.)20%
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Outpatient Services
Outpatient surgery at an Ambulatory Surgery Center 10%
Outpatient surgery at a Hospital-based facility 20%
Colonoscopy (non-preventive) at an Ambulatory Surgery Center 10%
Colonoscopy (non-preventive) at a Hospital-based facility 20%
Outpatient dialysis, infusion, chemotherapy and radiation therapy 20%
Cardiac Rehabilitation (post-surgery) First 16 visits Covered in full then 20% after deductible
Outpatient rehabilitative services: physical, occupational or speech therapy
(Limited to 30 visits per calendar year; up to 30 additional visits per specified condition. Limits do not apply to Mental Health and Substance Use Disorder Services.)20%
Outpatient habilitative services: physical, occupational or speech therapy
(Limited to 30 visits per calendar year; up to 30 additional visits per specified condition. Limits do not apply to Mental Health and Substance Use Disorder Services.)20%
Vision Therapy (convergence insufficiency)
(Limited to 12 visits per lifetime)20%
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Maternity Services
Prenatal visits Covered in full
Delivery and postnatal physician/provider visits
Certified nurse midwife
Primary Care Provider
OB/GYN Physician/Provider
All other licensed maternity providers10%
10%
20%
20%
Inpatient Hospital/facility services 20%
Routine newborn nursery care 20%
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Medical Equipment, Supplies and Devices
Medical equipment, appliances, prosthetics/orthotics and supplies 20%
Diabetes supplies (such as lancets, test strips, needles, and glucose monitors) 20%
Hearing aids (Limited to one aid per ear every 3 calendar years) 20%
Removable custom shoe orthotics 20%
Oral Sleep Apnea Appliance 20%
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Mental Health and Substance Use Disorder
Inpatient and residential services 20%
Day treatment, intensive outpatient, and partial hospitalization services 20%
Outpatient provider visits
In-Person
VirtuallyFirst 3 visits $5 then
$30
$10
Applied Behavior Analysis 20%
-
Home Health and Hospice
Home health care 20%
Hospice care Covered in full
Respite care (limited to Members receiving Hospice care; limited to 5 consecutive days, up to 30 days per lifetime) 20%
-
Biofeedback
Biofeedback for specified diagnosis (limited to 10 visits per lifetime, limits do not apply to Mental Health and Substance Use Disorder Services) 20%
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Chiropractic Manipulation and Acupuncture
Chiropractic manipulations (limited to 20 visits per calendar year) $25
Acupuncture (limited to 12 visits per calendar year) $25
Prescription Drugs
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Up to a 30-Day Supply
Up to a 30-day supply from a participating retail, preferred or specialty pharmacy Tier 1 Covered in full
Tier 2 $10
Tier 3 $50
Tier 4 50%
Tier 5 50% with $200 per script cap
Tier 6 50%
-
90-Day Supply: Preferred Retail
90-day supply from a participating preferred retail pharmacy Tier 1 Covered in full
Tier 2 $30
Tier 3 $150
Tier 4 50%
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90-Day Supply: Mail Order
90-day supply from a participating mail order pharmacy Tier 1 Covered in full
Tier 2 $20
Tier 3 $100
Tier 4 45%
Routine Vision Services
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Pediatric Vision Services (under age 19)
Routine eye exam (limited to 1 exam per calendar year) Covered in full
Lenses (limited to 1 pair per calendar year)
Single vision
Lined bifocal
Lined trifocal
Lenticular lensesCovered in full
Frames (limited to 1 pair per calendar year; select from VSP’s Otis & Piper ™ Eyewear Collection) Covered in full
Contact lens services and materials in place of glasses
Standard: 1 pair per calendar year (1 contact lens per eye)
Monthly: 6 month supply per calendar year (6 lenses per eye)
Bi-weekly: 3 month supply per calendar year (6 lenses per eye)
Dailies: 3 month supply per calendar year (90 lenses per eye)Covered in full
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Adult Vision Services
Routine eye exam (limited to 1 exam per calendar year) $25
Pediatric Dental Services (under age 19)
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Preventive
Routine exams (1 every 6 months) Covered in full
Bitewing X-rays (1 set every 12 months)
Covered in full
Cleanings (1 every 6 months)
Covered in full
Topical fluoride (1 every 6 months)
Covered in full
Sealants (1 per tooth every 5 years; limited to the unrestored occlusal surfaces of permanent molars) Covered in full
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Basic
Restorative fillings 50%
Space maintainers (1 per space) 50%
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Major
Oral surgery (extractions and other minor surgical procedures) 50%
Endodontics and periodontics 50%
Stainless steel crowns (1 per lifetime for primary teeth; 1 every 24 months for permanent teeth) 50%
Porcelain crowns (1 per tooth in a 7 year period) 50%
Denture and bridge work (construction or repair of fixed bridges, partials and complete dentures) limited to once 7 years.
Dentures not covered for members under age 16.
Partial dentures if placed within 2 months of the extraction of an anterior tooth or for missing anterior teeth for members age 16 and under.50%
Athletic mouthguards (Limited to 1 every 12 months for under age 16 and 1 every 24 months for ages 16 and over) 50%
Occlusal guard (nightguard) covered up to $200 every 5 years 50%
Orthodontia is covered to treat cleft palate with or without cleft lip 50%
We want you to get the most out of your coverage. Whether your goals include better health and fitness or you just need a little extra assistance, our health plans include great perks and care options to help keep you healthy.
Member Perks
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LifeBalance
Health and well-being go hand in hand.
That’s why we’ve partnered with LifeBalance to give you and your family access to discounts on more than 20,000 recreational, cultural, and travel related businesses and activities.
Learn more -
ID Protection
Enjoy the peace of mind you deserve.
We’ve partnered with Assist America Identity Theft Protection® to give you 24/7 access to identity theft protection experts, fraud monitoring and warning notifications, resolution services, and lost or stolen card assistance.
Learn more -
Travel Assistance
Accidents happen. We've got you covered.
We’ve partnered with Assist America Travel Assistance® to provide you with the logistical support for your emergency medical needs when you’re traveling internationally or at least 100 miles or more from your home.
Learn more -
Health Coaching
We can help you work towards a healthier you.
It's time to team up. Whether you'd like to increase your activity level, reduce stress, improve your eating habits, lose weight, quit tobacco or just feel better every day, a Providence health coach can help. We’re here to remove barriers, support your efforts, motivate you when you need a nudge and be a resource on your journey to a healthier, happier you.
Learn more -
One Pass SelectTM
Save on your fitness membership.
Discover whole body health in one affordable program. Choose a membership tier that fits your lifestyle and access digital fitness apps, gym memberships and home grocery delivery services.
Learn more -
Behavioral Health Resources
We're here for you when you need us.
Meet with a licensed mental health provider that best suits your needs, fully confidential – always.
Learn more
Member Care Options
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ProvRn - Free*
Access to care 24/7.
Speak with a registered nurse anytime, any day. An easy first step when you have symptoms and you want to know if you need face-to-face care.
Learn more -
ExpressCare Virtual - Free*
Getting the care you need, when you need it.
Talk with a provider from anywhere using your tablet, smartphone, or computer. This is a great option for prescriptions and treatment that doesn’t require hands on care. Available nationwide.
Learn more
*ExpressCare Virtual visits are free with most Providence health plans. HSA members must first meet the plan deductible, but the cost of an ExpressCare visit is significantly less than an office visit. Ancillary services, such as laboratory tests, may incur additional cost-shares.
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ExpressCare Clinics - Free
Same day in-person treatment.
When you need to see someone and your regular care provider is not available. With many convenient locations, it’s easy to find a clinic near you.
Learn more -
Primary Care - $
Your primary healthcare partner.
Primary care providers develop a relationship with you and know your health history. Visit them for check-ups, managing chronic conditions, and specialist referrals.
Learn more -
Urgent Care - $$
When you need help right away.
Urgent care is where you turn when you know you need help and can’t wait for an appointment. This is best for minor injuries, cuts, burns, pains, and sprains.
Learn more -
Emergency Care - $$$
When you think you may be in danger.
Use emergency care for symptoms like suspected heart attack, stroke, severe abdominal pain, poisoning, choking, loss of consciousness, and uncontrolled bleeding.
Learn more
If you think your life or well-being could be in serious danger, call 911 immediately.