Connect 1500 Gold
Providence Health Plan
Plan overview
Medical deductible
Individual: $1500
Family: $3000
Per Person: $1500
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $9000
Family: $18000
Per Person: $9000
Office visit
Primary Doctor
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: $5 copay for the first three in-network Primary Care Provider visits per year. Practitioners assisting specialists will be charged at the specialist copay.
Specialist
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 30
Limit Unit: Days per Month
Benefit Explanation: The cost share shown is the most common amount paid by a member for drugs in this category. Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $35 max out of pocket for 30 day supply prior to deductible.
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 30
Limit Unit: Days per Month
Benefit Explanation: Tier 4- 50% up to $200 per 30-day script cap. The cost share shown is the most common amount paid by a member for drugs in this category. Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $35 max out of pocket for 30 day supply prior to deductible.
Generic drugs
CoPay: $10.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 30
Limit Unit: Days per Month
Benefit Explanation: The cost share shown is the most common amount paid by a member for drugs in this category. Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $35 max out of pocket for 30 day supply prior to deductible.
Specialty drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 30
Limit Unit: Days per Month
Benefit Explanation: Tier 5 Specialty Drugs - 50% up to $300 per 30-day script cap. The cost share shown is the most common amount paid by a member for drugs in this category. Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $35 max out of pocket for 30 day supply prior to deductible
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: $250.00 Copay after deductible
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Urgent care facility
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Major dental care
Routine dental checkups for children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).