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Benefits 101

Your benefits are designed to support your well-being. As a Providence Health Plan member you can count on comprehensive benefits and provider choice.

Explore the following topics to learn about your plan’s benefits:

  • Member materials
    Benefit summaries
     
    Summary of Benefits and Coverage



    These benefit summaries and SBCs do not describe the savings account associated with the medical plan nor do they list the possible financial incentive that Providence will contribute to the account if you choose to complete certain healthy activities by the given deadline. We encourage you to learn more about these types of savings accounts and what incentives may be available to you.

     

    More information about your health plan can be found in the Summary Plan Description located on the HR portal under the Resources tab.

  • Pharmacy resources
    Formulary

    Providence Health Plan provides a comprehensive prescription drug formulary designed to promote safe, effective, and affordable drug therapy.

     

    2021 plans formulary

     

    2020 plans formulary

     



    Tips to help you save when need a prescription
    • Choose generics when possible.
    • Use a participating retail pharmacy; refer to the online provider directory
    • Fill medication taken on a regular, recurring basis for a chronic or long-term health condition (i.e., “maintenance medication”) at a preferred retail or mail-order pharmacy. A retail pharmacy can provide up to a three-month supply of prescription medications. Search the online provider directory for a pharmacy near you.
    • Have certain medications prior-authorized (see prior authorization below for more information).



    Participating pharmacies

    As a member, you have access to more than 36,000 participating pharmacies, including retail, preferred retail, mail-order and specialty. Find one in our online provider directory.

    Mail-order pharmacy:

    Postal Prescription Services

    www.ppsrx.com

    503-797-2100 or 800-552-6694

    Monday – Friday, 6 a.m. to 6 p.m.; Saturday, 9 a.m. to 2 p.m. (Pacific Time)
    Mailing address: P.O. Box 2718, Portland, OR 97208

    Automated refill line available 24/7, 365 days a year: 800-552-6694

     


    Pharmacy FAQ

    Get answers to frequently asked questions about prescription drug coverage, prior authorization, using the formulary, and specialty medication.

     

    Go now
  • Prior authorization
    Certain services require a prior authorization before you receive care, meaning that before you receive care, the service must be pre-approved by Providence Health Plan. Here’s what you should know about prior authorization:

    Certain services need to be approved before you receive them from a health care provider. Sometimes you need to get the prior authorization; sometimes your provider will get the approval.


    Make sure to discuss prior authorization with your provider when you are considering one of the following procedures:


    • Inpatient hospital admissions, including maternity
    • High tech diagnostic imaging, such as MRI, MRA, SPECT, CT, CTA, PET, Nuclear Cardiology (American Imaging Management authorizes these services; contact AIM at (800-920-1250)
    • Mental Health and/or Chemical Dependency services (PBH, a team of experts in mental health – sometimes called "behavioral health," is the authorizing agent: 800-711-4577)
    • Select outpatient procedures, included but not limited to these categories:

      • Miscellaneous cosmetic, reconstructive, nasal, oral/dental/orthognathic procedures
      • Cervical, thoracic and lumbar spinal surgeries
      • All bariatric services
      • Organ/tissue and bone marrow transplants (including pre-transplant evaluations and HLA typing)
      • Uvulectomy, uvulopalatophyaryngoplasty (UPPP), laser-assisted uvulopalatoplasty (LAUP)
      • Select hip, knee and shoulder procedures
      • Sleep studies and/or treatment of sleep disorders
      • Skilled nursing facility admissions
      • Inpatient rehabilitation facility admissions
      • Inpatient hospice
      • Pulmonary rehabilitation
      • Cardiac rehabilitation
      • General anesthesia for dental services
      • Procedures/surgeries/treatment that may be considered experimental or investigational
      • Genetic testing (Cytogenetic Studies) and counseling
      • Neuropsychological testing
      • Prosthetics
      • Select Durable Medical Equipment including but not limited to the following categories:
      • Power-wheel chairs & supplies
      • Seat Lift Mechanisms
      • Select nerve stimulators
      • Skin substitutes
      • Oral appliances
      • Flexion/Extension devices
      • Wound Therapy pumps
      • Speech Generating devices
      • Purchase of CPAP post trial rental period

    Select injectable medications also require prior authorization. See your pharmacy medical services prior-authorization list (PDF) for details.

    The list of services needing prior authorization is not exhaustive. For a complete list of services that require prior authorization, please refer to your summary plan description.


     


    Important information about how prior authorization works

    Talk with your provider about getting prior authorization. Many times a provider will obtain the prior authorization on your behalf. You can call Providence Health Plan customer service at 800-878-4445 to verify if prior authorization has been obtained. If you do not obtain prior authorization for services received from an out-of-network provider, a financial penalty may apply.

  • Health and wellness resources
    Make the most of your plan membership with discounts and online resources for managing costs, services and quality.

    Recreation

    Are you looking to buy some new gear to help you get in shape? Thinking about joining a gym, taking a healthy cooking class or signing up for some kayaking lessons? Whatever it is you want to do to stay in shape and help maintain a healthy weight, our recreational discount partner LifeBalance can help you save money doing it. LifeBalance offers great discounts on health and wellness-related activities, as well as recreation and cultural activities, and discounts on travel, including on hotels, cruises and a variety of adventure tours.

    Log in or register for a free myProvidence account to access discounts.



    Alternative care

    We think it’s important for you to have alternatives when it comes to the kind of care you receive, which is why we partner with ChooseHealthy™ to offer discounts on acupuncture, chiropractic care, massage therapy and dietitian services. You and your qualified dependents can take advantage of these discounted services by selecting from the ChooseHealthy™ network of providers. By partnering with a ChooseHealthy provider, you receive a 25 percent discount off of the participating provider’s usual and customary fees.

    ChooseHealthy™
    877-335-2746
    www.choosehealthy.com/providence



    Smoking cessation

    Smoking is a powerful addiction. Quitting takes practice, patience and support. You can get the help you need with award-winning support groups and telephone counseling programs:


    • Tobacco quit line – A free telephone service to help you develop a personalized quit plan and find counseling and resources in your area. Call 800‑QUIT‑NOW or 877‑2NO‑FUME (Spanish).
    • Free & Clear – A telephone-based program designed for smokers who want a structured program but cannot attend regular classes. Call 800-292-2336.
  • Nutritional counseling
    Tired of the weight roller coaster? Tired of trying the latest fad diet? Just tired of being tired? We hear you. Proper nutrition — a stable, consistent approach to it — is essential for peak body performance and preventing health concerns.

    Whether you're looking to lose weight, want to eat smarter, or battling an eating disorder, you and your dependents have access to nutritional counseling benefits. The first four visits are covered in full, meaning that you pay nothing out of pocket for these services. After your fourth visit, additional visits are paid according to your “office visits” benefit. See your member materials for your plan's benefits.

     

    Why nutritional counseling?

    We encourage you to fully understand and use your health plan benefits. When you access nutritional counseling services, you'll benefit from:

     

    • A personalized plan. You'll work with a nutrition counselor to develop a plan that works from where you are. Your needs will be thoroughly assessed and analyzed to develop a plan and pace that's right for you.
    • A healthier you. Proper nutrition and appropriate exercise will provide you enough energy to make it through each day. Without a proper diet and exercise level, you're at risk for health concerns.
    • Knowledge of foods that aren't scary and that taste good. Good nutrition isn't limited to bland, boring veggies. When you work with a nutrition counselor, you'll learn that there are foods that are not only good for you, but also taste good.
     

    Find the provider that's right for you

    To find the provider that's right for you, search the online provider directory.

Contact customer service

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