| In-network | Out-of-network | |
|---|---|---|
| Inpatient Hospital Coverage1 | $300 copay each day for days 1-6 $0 copay each day for day 7 and beyond | 50% of the total cost per admission |
| Outpatient Hospital Coverage1 | $250 copay for outpatient surgery at a hospital facility | 50% of the total cost |
| Ambulatory Surgery Center1 | $250 copay for outpatient surgery at an Ambulatory Surgery Center | 50% of the total cost |
| Primary Care Provider visit | $15 copay | 50% of the total cost |
| Specialist visit | $30 copay | 50% of the total cost |
| Preventive Care | $0 copay | 50% of the total cost |
| Emergency Care | $130 copay If you are admitted to the hospital within 24 hours, you do not have to pay your copay for emergency care. | |
| Urgently Needed Services | $25 copay If you are admitted to the hospital within 24 hours, you do not have to pay your copay for urgent care. | |
Plan Details
Providence Medicare Reverence (HMO-POS)
Overview
|
Monthly Premium |
$25 |
|
Annual Deductible |
$0 |
|
Maximum Out-of-Pocket |
$6,750 In-network |
Additional Benefits
Preventive Dental
$250 eyeware allowance and eye exam
Copays for hearing aids + $0 exams
$100 every 6 months for OTC items
Gym membership
Extra Help
Extra Help, also known as a Part D Low-Income Subsidy, or LIS, is a federal program that helps lower prescription costs and Part D (prescription) costs for Medicare Advantage members. Learn more about Extra Help by connecting with one of our team members who can help walk you through how the program works.
Learn moreProvider Network
Search the integrated network to find in-network providers or pharmacies. When searching, please select your plan as your provider network.
Search the networkImportant information about this plan
This plan is available in Clackamas, Hood River, Lane, Multnomah, Washington and Yamhill Counties in Oregon and Benton, Clark, Franklin, Snohomish, Spokane and Walla Walla Counties in Washington.
Does not include any Part B premium you may have to pay. You must continue to pay your Medicare Part B premium.
- Find out if you qualify for Extra Help with your premiums
- Medical appeals, determination, and grievance processes
For more information about Providence Medicare Advantage Plans, please contact the sales team.
This information is available in a different format, including audio CDs. If you need plan information in another format, please call Customer Service at 503-574-8000 or 1-800-603-2340 (TTY: 711). Service is available between 8 a.m. to 8 p.m. (Pacific Time) 7 days a week from October 1st through March 31st and Monday - Friday, from April 1st through September 30th.
Important note about these benefits
Our plan members get all the benefits covered by Original Medicare, plus some extras for being a Providence Medicare Advantage Plans member.
Benefit Summary
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Benefits
-
Diagnostic Services + Labs & Imaging1
In-network Out-of-network Diagnostic radiology services (e.g. MRI, ultrasounds, CT Scans) 20% of the total cost up to $250 per day 50% of the total cost Therapeutic radiology services 20% of the total cost 50% of the total cost Outpatient x-rays $15 copay 50% of the total cost Diagnostic test and procedures 20% of the total cost 50% of the total cost Lab services $0 copay 50% of the total cost -
Hearing Services
In-network Out-of-network Medicare-covered $30 copay 50% of the total cost Routine exam $0 copay Not covered Hearing Aids $499 copay per hearing aid - Standard
$699 copay per hearing aid - Advanced
$999 copay per hearing aid - PremiumNot covered -
Dental Services
In-network Out-of-network Medicare-covered $30 copay 50% of the total cost Embedded Preventive $0 copay includes exams, cleanings, X-rays, fluoride treatment. Limits apply. 20% of the total cost includes exams, cleanings, x-rays, fluoride treatment. Limits apply. Optional Covered for additional premium. Click for more details. -
Vision Services
In-network Out-of-network Medicare-covered $30 copay
$0 copay for glaucoma screening50% of the total cost per exam
50% of the total cost for glaucoma screeningRoutine exam There is no coinsurance or copayment for one routine vision exam (including refraction) per calendar year Medicare-Covered Eyewear $0 copay for one pair of Medicare-covered eyeglasses or contact lenses after each cataract surgery 50% of the total cost for one pair of Medicare-covered eyeglasses or contact lenses after each cataract surgery Routine eyeglasses or contact lenses Allowance of up to $250 per calendar year for any combination of routine prescription eyewear -
Mental Health Services1
In-network Out-of-network Inpatient visit $275 copay each day for days 1-6
$0 copay for days 7-9050% of the total cost per admission Outpatient individual and group therapy visit $30 copay 50% of the total cost -
Skilled Nursing Facility1
In-network Out-of-network Skilled Nursing Facility $0 copayment for days 1-20
$218 copayment each day for days 21-10050% of the total cost for each benefit period (days 1-100) -
Physical Therapy1
In-network Out-of-network Physical Therapy $30 copay 50% of the total cost -
Ambulance1
In-network Out-of-network Ambulance $275 copay -
Medicare Part B Drugs1
In-network Out-of-network Medicare Part B Drugs 0% - 20% of the total cost
(Insulin cost share up to $35 per month)50% of the total cost
(Insulin cost share up to $35 per month) -
Alternative Care1
In-network Out-of-network Alternative Care Medicare covered chiropractic: $15 copay
Medicare covered acupuncture: $30 copayMedicare covered chiropractic and acupuncture: Not covered -
Meal Delivery Program
In-network Out-of-network Meal Delivery Program
(post-discharge only)$0 copay for 2 meals per day for 14 days, following a qualifying inpatient hospitalization Not covered -
Over-the-Counter Items
In-network Out-of-network Over-the-Counter Items $100 allowance every 6 months (retail card, catalog, online, mail, and telephonic ordering) Over-the-counter items can only be purchased from catalog or approved retailers -
Personal Emergency Response System
In-network Out-of-network Personal Emergency Response System (PERS) $0 copay Not covered -
Fitness Program
In-network Out-of-network Fitness Program $0 copay for monthly gym memberships with participating fitness clubs -
Wig
In-network Out-of-network Wig There is no coinsurance or copayment for one wig due to hair loss from chemotherapy.
1Services may require prior authorization.
Some dentists do not bill insurance. If you see a dentist that doesn’t bill insurance, you will need to pay cash and submit a reimbursement request form.
Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.
Some dentists do not bill insurance. If you see a dentist that doesn’t bill insurance, you will need to pay cash and submit a reimbursement request form.
Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.
Page current as of: 10/1/2025