Providence Health Plan

Providence Oregon Standard Gold Plan - Choice Network

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	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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