Plan Details

Connect 1500 Gold

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Overview

Annual Deductible

$1,500/$3,000

Out-of-Pocket Maximum

$8,200/$16,400

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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
    Virtual Visits (such as Providence ExpressCare Virtual)

    Covered in full

    Providence Express Care Retail Health Clinic visits

    Covered in full

    Virtual phone and video visits to a specialist

    $35

  • Preventive Care
    Periodic health exams and well-baby care

    Covered in full

    Routine immunizations and shots

    Covered in full

    Colonoscopy (preventive, age 50+)

    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

    $30

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

    $30

    Office visits to specialists

    $50

    Inpatient Hospital visits

    20%

    Allergy shots and allergy serums, injectable and infused medications

    20%

    Surgery and anesthesia in an office or facility

    20%

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

    20%

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

    20%

    Sleep studies

    20%

  • Emergency Care and Urgent Care Services
    Emergency Services (Deductible applies)
    (For Emergency Medical Conditions only. If admitted to the Hospital, all Services subject to inpatient benefits.)
       In-Network
       Out-of-Network

    $250 then 20%

    $250 then 20%

    Emergency medical transportation (air and/or ground)
    (Emergency transportation is covered regardless of whether or not the provider is an In-Network Provider.)

    20%

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

    $50

    $50

  • Hospital Services
    Inpatient/Observation care

    20%

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

    20%

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

    20%

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

    20%

  • Outpatient Services
    Outpatient surgery at an Ambulatory Surgery Center

    10%

    Outpatient surgery at a Hospital-based facility

    20%

    Colonoscopy (non-preventive) at an Ambulatory Surgery Center

    10%

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

    20%

    Outpatient dialysis, infusion, chemotherapy and radiation therapy

    20%

    Cardiac Rehabilitation (post-surgery)

    First 16 visits Covered in full then 20% after deductible

    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.)

    20%

    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.)

    20%

  • Maternity Services
    Prenatal visits

    Covered in full

    Delivery and postnatal physician/provider visits
       Certified nurse midwife
       Primary Care Provider
       OB/GYN Physician/Provider

    10%

    10%

    20%

    Inpatient Hospital/facility services

    20%

    Routine newborn nursery care

    20%

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

    20%

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

    20%

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

    20%

    Removable custom shoe orthotics
    (Limited to $200 per calendar year)

    20%

  • Mental Health and Chemical Dependency
    Inpatient and residential services

    20%

    Day treatment, intensive outpatient, and partial hospitalization services

    20%

    Outpatient provider visits

    $30

    Applied Behavior Analysis

    20%

  • Home Health and Hospice
    Home health care

    20%

    Hospice care

    Covered in full

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

    20%

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

    20%

  • Chiropractic Manipulation and Acupuncture
    Chiropractic manipulations and acupuncture (limited to 3 visits combined per calendar year)

    $25

Prescription Drugs

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

    Covered in full

    Tier 2

    $10

    Tier 3

    $50

    Tier 4

    50%

    Tier 5

    50% with $200 per script cap

    Tier 6

    50%

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

    Covered in full

    Tier 2

    $30

    Tier 3

    $150

    Tier 4

    50%

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

    Covered in full

    Tier 2

    $20

    Tier 3

    $100

    Tier 4

    45%

  • Pharmacies

    Your prescription drug benefit requires that you fill your prescriptions at a Participating Pharmacy.

     

    There are four types of participating pharmacies:

     

    • Retail: a Participating Pharmacy that allows up to a 30-day supply as outlined in your handbook of short-term and maintenance prescriptions.
    • Preferred Retail: a Participating Pharmacy that allows up to a 90-day supply of maintenance prescriptions and access to up to a 30-day supply of short-term prescriptions.
    • Specialty: a Participating Pharmacy that allows up to a 30-day supply of specialty and self-administered chemotherapy prescriptions. These prescriptions require special delivery, handling, administration and monitoring by your pharmacist.
    • Mail Order: a Participating Pharmacy that allows up to a 90-day supply of maintenance prescriptions and specializes in direct delivery to your home. To order prescriptions by mail, your provider may call in the prescription or you can mail your prescription along with your Member identification number to one of our participating mail-order pharmacies.

     

    Learn more about our participating pharmacies here.

  • Using Your Prescription Drug Benefit

    To find if a drug is covered under your plan use our online directory.

     

    Note that your plan’s formulary includes ACA Preventive drugs which are medications that are covered at no cost when received from participating pharmacies as required by the Patient Protection and Affordable Care Act.

     

    • FDA-approved women’s contraceptives, as listed on your formulary, are covered at no cost for up to a 12-month supply, after a 3-month initial fill, at any Participating Pharmacy.
    • You may purchase up to a 90-day supply of maintenance drugs using a participating mail-service or preferred retail pharmacy. Not all drugs are considered maintenance prescriptions, including compounded drugs and drugs obtained from specialty pharmacies.
    • If you or your provider request or prescribe a brand-name drug when a generic is available, regardless of reason, you will be responsible for the cost difference between the brand-name and generic drug in addition to the Tier 4 or Tier 6 copayment or coinsurance indicated on the benefit summary. Your total cost, however, will never exceed the actual cost of the drug.

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

  • Adult Vision Services
    Routine eye exam (limited to 1 exam per calendar year)

    $25

Pediatric Dental Service (under age 19)

  • Preventive
    Routine Exams
    2 per every 12 months

    Covered in full

    Bitewing X-rays
    4 per every 6 months

    Covered in full

    Cleanings
    1 per every 6 months

    Covered in full

    Topical Fluoride
    1 per every 6 months

    Covered in full

    Fissure sealants
    1 service per tooth (molar) per every 60 months

    Covered in full

    Space Maintainers

    Covered in full

  • Basic
    Restorative fillings

    50%

  • Major
    Oral surgery (extractions and other minor surgical procedures)

    50%

    Endodontics and Periodontics

    50%

    Stainless Steel Crowns/Anterior Primary or Posterior Primary/Permanent
    1 service per tooth every 7 years

    50%

    Porcelain Crowns
    1 service per tooth every 7 years for children ages 16 and older (limited to tooth numbers 6-11, 22 and 27 only)

    50%

    Denture and bridge work (construction or repair of fixed bridges, partials and complete dentures)
    Limited to 1 every 10 years for complete dentures and 1 every 10 years for partials for Members ages 16 and older

    50%

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™

    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 10,000 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 Virtual – Free*

    Getting the care you need, when you need it.

    Talk with a provider from anywhere using your tablet, smartphone, or computer. This is a great option for prescriptions and treatment that doesn’t require hands on care. Available nationwide.

    Learn more

    *ExpressCare Virtual visits are free with most Providence health plans. HSA members must first meet the plan deductible, but the cost of an ExpressCare visit is significantly less than an office visit. Ancillary services, such as laboratory tests, may incur additional cost-shares.

  • 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 (some in your local Walgreens), it’s easy to find a clinic near you.

    Learn more

    *ExpressCare Clinic visits are free with most Oregon Providence health plans. HSA members must first meet the plan deductible. Ancillary services, such as laboratory tests, may incur additional cost-shares. Washington health plans have a copay when utilizing ExpressCare Clinics.

  • 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 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.

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