Plan Details

Providence Oregon Standard Bronze - Choice Network

견적 요청

Overview

Annual Deductible

$8,800/$17,600

Out-of-Pocket Maximum

$8,800/$17,600

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Choice Network

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Formulary N

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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

  • On-Demand Visits
    Providence ExpressCare Virtual visits

    Covered in full

    Providence ExpressCare Retail Health Clinic visits

    Covered in full

  • 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

  • Physician/Professional Services
    Office visits to a Primary Care Provider
       In-Person
       Virtually

    $50

    $50

    Office visits to an Alternative Care Provider (In-Person or Virtually) (such as naturopath)
    (Chiropractic manipulation and acupuncture services are covered separately from the office visit at the levels listed for those benefits.)

    $100

    Office visits to specialists (In-Person or Virtually)

    $100

    Inpatient Hospital visits

    Covered in full

    Allergy shots and allergy serums, injectable and infused medications

    Covered in full

    Surgery and anesthesia in an office or facility

    Covered in full

  • Diagnostic Services
    X-ray, lab and testing Services (includes ultrasound)

    Covered in full

    High-tech imaging Services (such as PET, CT or MRI)

    Covered in full

    Sleep studies

    Covered in full

  • 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

    Covered in full

    Covered in full

    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-Network

    Covered in full

    Covered in full

    Urgent Care visits (for non-life threatening illness/minor injury)
       In-Network
       Out-of-Network

    $100

    Covered in full

  • Hospital Services
    Inpatient/Observation care

    Covered in full

    Skilled Nursing Facility (limited to 60 days per calendar year)

    Covered in full

    Inpatient rehabilitative care
    (Limited to 30 days per calendar year; 60 days for head/spinal injuries. Limits do not apply to Mental Health Services.)

    Covered in full

    Inpatient habilitative care
    (Limited to 30 days per calendar year; 60 days for head/spinal injuries. Limits do not apply to Mental Health Services.)

    Covered in full

  • Outpatient Services
    Outpatient surgery at an Ambulatory Surgery Center

    Covered in full

    Outpatient surgery at a Hospital-based facility

    Covered in full

    Colonoscopy (non-preventive) at an Ambulatory Surgery Center

    Covered in full

    Colonoscopy (non-preventive) at a Hospital-based facility

    Covered in full

    Outpatient dialysis, infusion, chemotherapy and radiation therapy

    Covered in full

    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 Services.)

    $50

    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 Services.)

    $50

    Vision Therapy (convergence insufficiency)
    (Limited to 12 visits per lifetime)

    Covered in full

  • Maternity Services
    Prenatal visits

    Covered in full

    Delivery and postnatal physician/provider visits

    Covered in full

    Inpatient Hospital/facility services

    Covered in full

    Routine newborn nursery care

    Covered in full

  • Medical Equipment, Supplies and Devices
    Medical equipment, appliances, prosthetics/orthotics and supplies

    Covered in full

    Diabetes supplies (such as lancets, test strips, needles, and glucose monitors)

    Covered in full

    Hearing aids (Limited to one aid per ear every 3 calendar years)

    Covered in full

    Removable custom shoe orthotics

    Covered in full

  • Mental Health and Substance Use Disorder
    Inpatient and residential services

    Covered in full

    Day treatment, intensive outpatient, and partial hospitalization services

    Covered in full

    Outpatient provider visits
       In-Person
       Virtually

    $50

    $50

    Applied Behavior Analysis

    Covered in full

  • Home Health and Hospice
    Home health care

    Covered in full

    Hospice care

    Covered in full

    Respite care (limited to Members receiving Hospice care; limited to 5 consecutive days, up to 30 days per lifetime)

    Covered in full

  • Biofeedback
    Biofeedback for specified diagnosis (limited to 10 visits per lifetime)

    Covered in full

  • Chiropractic Manipulation and Acupuncture
    Chiropractic manipulations (limited to 20 visits per calendar year)

    $50

    Acupuncture (limited to 12 visits per calendar year)

    $50

Prescription Drugs

  • Up to a 30-Day Supply
    Up to a 30-day supply from a participating retail, preferred or specialty pharmacy
    Tier 1

    $20

    Tier 2

    $20

    Tier 3

    Covered in full

    Tier 4

    Covered in full

    Tier 5

    Covered in full

    Tier 6

    Covered in full

  • 90-Day Supply: Preferred Retail
    90-day supply from a participating preferred retail pharmacy
    Tier 1

    $60

    Tier 2

    $60

    Tier 3

    Covered in full

    Tier 4

    Covered in full

  • 90-Day Supply: Mail Order
    90-day supply from a participating mail order pharmacy
    Tier 1

    $40

    Tier 2

    $40

    Tier 3

    Covered in full

    Tier 4

    Covered in full

Routine Vision Services

  • 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 lenses

    Covered 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

Benefit Summary PDF

We want you to get the most for your money. 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 make achieving your True Health that much easier.

Member Perks

  • 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
  • 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
  • ChooseHealthy®

    Save big while you achieve your health goals.

    We want to give you every opportunity we can to help you achieve your True Health. Save big on wellness products and memberships that will help you thrive on your road to better health.

    Learn more
  • Active&Fit Direct™

    Big discounts on your fitness membership.

    Whether you’re ready to kick-start your routine — or just looking to level up — the Active&Fit Direct™ program allows you to choose from more than 16,000 participating fitness centers and YMCAs nationwide for $25 a month (plus a $25 enrollment fee and applicable taxes; 2-month commitment required).

    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
  • 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

Member Care Options

  • ProvRN – Free

    Access to care 24/7.

    Health issues don’t fit neatly into a 9 to 5 schedule — and neither should your access to health information. Providence Health Plan members can call ProvRN around the clock to ask questions about their health.

    Learn more
  • 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

    *Washington health plans may have a copay when utilizing ExpressCare Clinics. Washington health plans have a copay when utilizing ExpressCare Clinics.

  • ExpressCare 가상 진료 - 무료*

    필요할 때 필요한 치료를 받을 수 있습니다.

    태블릿, 스마트폰 또는 컴퓨터를 사용하여 어디에서나 제공업체와 대화할 수 있습니다. 이는 직접 치료가 필요하지 않은 처방 및 치료를 위한 훌륭한 옵션입니다. 전국적으로 이용 가능합니다.

    자세히 알아보기

    ExpressCare Virtual 진료는 대부분의 Providence Health Plan에서 무료입니다. HSA 회원은 우선 플랜 공제액을 충족해야 하지만 ExpressCare 방문 비용은 진료실 방문 비용보다 상당히 낮습니다. 임상실험실 검사와 같은 보조 서비스에는 추가 분담금이 발생할 수 있습니다.

  • 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 ever think your life or well-being could be in serious danger, call 911 immediately.

Individual & Family Resources

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