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Providence Health Plan

Providence Oregon Standard Gold Plan - Choice Network

Plan Overview

Medical Deductable
  • Individual: $1,500.00
  • Family: $3,000
  • Per Person: $1,500
Prescription Drug Deductible
  • Individual: $0.00
  • Family: $0
  • Per Person: $0
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $7,300.00
  • Family: $14,600
  • Per Person: $7,300

Office Visit

Primary Doctor
  • CoPay: $20.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Specialist
  • CoPay: $40.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $30.00
  • 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: $75 max out of pocket for 30 day supply prior to deductible.
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00%
  • 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: $75 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: $75 max out of pocket for 30 day supply prior to deductible.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00%
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Days per Month
  • Benefit Explanation: 50% with $500 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: $75 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: Not Applicable
  • CoInsurance: 20.00% Coinsurance after deductible
  • Covered: Covered
Urgent Care Facility
  • CoPay: $60.00
  • CoInsurance: Not Applicable
  • Covered: Covered

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

Major Dental Care

Routine Dental Checkups for Children
  • Covered: Not Covered
Routine Dental Checkups for Adults
  • Covered: Not Covered
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