Plan Details

Columbia 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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Choice Network

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Formulary M

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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
    Providence ExpressCare Virtual visits

    Covered in full

    Providence ExpressCare Retail Health Clinic visits

    Covered in full

  • Preventive Care
    Periodic health exams and well-baby care

    Covered in full

    Routine immunizations and shots

    Covered in full

    Colonoscopy (preventive, age 45+)

    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 (In-Person or Virtually)

    $30

    Office visits to an Alternative Care Provider (In-Person or Virtually) (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 (In-Person or Virtually)

    $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
    (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.)
       In-Network
       Out-of-Network

    20%

    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. Limits do not apply to Mental Health Services.)

    20%

    Inpatient habilitative care
    (Limited to 30 days per calendar year. Limits do not apply to Mental Health Services.)

    20%

  • Temporomandibular joint (TMJ) services
    Temporomandibular joint (TMJ) services
    (Limited to $1,000 per calendar year, up to $5,000 per lifetime)

    50%

  • 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. Limits do not apply to Mental Health Services.)

    20%

    Outpatient habilitative services: physical, occupational or speech therapy
    (Limited to 30 visits per calendar year. Limits do not apply to Mental Health Services.)

    20%

    Neurodevelopmental therapy

    20%

    Vision Therapy (convergence insufficiency)
    (Limited to 12 visits per lifetime)

    20%

  • Maternity Services
    Prenatal visits

    Covered in full

    Delivery and postnatal physician/provider visits

    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%

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

    20%

  • Mental Health and Substance Use Disorder
    Inpatient and residential services

    20%

    Day treatment, intensive outpatient, and partial hospitalization services

    20%

    Outpatient provider visits (In-Person or Virtually)

    $30

    Applied Behavior Analysis

    20%

  • Home Health and Hospice
    Home health care
    (Limited to 130 days per calendar year)

    20%

    Hospice care

    Covered in full

    Respite care (limited to Members receiving Hospice care; limited to 14 days per lifetime)

    20%

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

    20%

  • Chiropractic Manipulation, Acupuncture, and Massage Therapy
    Chiropractic manipulations (limited to 10 visits per calendar year)

    $25

    Acupuncture (limited to 12 visits per calendar year)

    $25

    Massage Therapy (Copayments and Coinsurance do not apply to your Out-of-Pocket Maximums) (limited to 10 visits 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%

Routine Vision Services

  • Pediatric Vision Services (under age 19)
    Routine eye exam (limited to 1 exam per calendar year)

    Covered in full

    Lenses (polycarbonate, plastic or glass; 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

    Covered in full

    Low Vision Services

    Covered in full

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 Direct™

    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 16,000 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 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, it’s easy to find a clinic near you.

    Learn more

    *Washington health plans may have a copay when utilizing ExpressCare Clinics. Washington health plans have a copay when utilizing ExpressCare Clinics.

  • 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.

  • 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 symptoms like 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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