| In-network | |
|---|---|
| Inpatient Hospital Coverage1 | $0 copay |
| Outpatient Hospital Coverage1 | $0 copay for outpatient surgery at a hospital facility |
| Ambulatory Surgery Center1 | $0 copay for outpatient surgery at an Ambulatory Surgery Center |
| Primary Care Provider visit | $0 copay |
| Specialist visit2 | $0 copay |
| Preventive Care | $0 copay |
| Emergency Care | $150 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 | $0 copay |
Plan Details
Providence Medicare Sycamore + Rx (HMO)
Overview
|
Monthly Premium |
$0 |
|
Annual Deductible |
$0 |
|
Maximum Out-of-Pocket |
$400 In-network |
Additional Benefits
Prescription drug coverage
$350 every 6 months for dental services
$0 Vision exams
Copays for hearing aids + $0 exams
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 networkFormulary
Search the online formularyImportant information about this plan
This plan is available in Orange County in California.
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 Diagnostic radiology services (e.g. MRI, ultrasounds, CT Scans) $0 copay Therapeutic radiology services $50 copay Outpatient x-rays $0 copay Diagnostic test and procedures $0 copay Lab services $0 copay -
Hearing Services
In-network Medicare-covered2 $0 copay Routine exam $0 copay Hearing Aids $499 copay per hearing aid - Standard
$699 copay per hearing aid - Advanced
$999 copay per hearing aid - Premium -
Dental Services
In-network Medicare-covered2 $0 copay Flex Dental Card $350 every 6 months for any dental services of your choosing -
Vision Services
In-network Medicare-covered2 $0 copay
$0 copay 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 -
Mental Health Services1
In-network Inpatient visit $0 copay Outpatient individual and group therapy visit $0 copay -
Skilled Nursing Facility1
In-network Skilled Nursing Facility $0 copayment for days 1-20
$100 copayment each day for days 21-100 -
Physical Therapy1
In-network Physical Therapy $0 copay -
Ambulance1
In-network Ambulance $100 copay -
Medicare Part B Drugs1
In-network Medicare Part B Drugs 0% - 20% of the total cost
(Insulin cost share up to $35 per month) -
Alternative Care1
In-network Alternative Care Medicare covered chiropractic or acupuncture: $0 copay with prior authorization -
Meal Delivery Program
In-network Meal Delivery Program
(post-discharge only)$0 copay for 2 meals per day for 14 days, following a qualifying inpatient hospitalization -
Over-the-Counter Items
In-network Over-the-Counter Items Not covered -
Personal Emergency Response System
In-network Personal Emergency Response System (PERS) Not covered -
Fitness Program
In-network Fitness Program $0 copay for monthly gym memberships with participating fitness clubs -
Wig
In-network Wig There is no coinsurance or copayment for one wig due to hair loss from chemotherapy.
1Services may require prior authorization.
2Services may require a referral from your doctor.
2Services may require a referral from your doctor.
Prescription Drugs
-
Prescription Drug Deductible
Yearly Deductible
Because there is no deductible for the plan, this payment stage does not apply to you.
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Preferred Retail + Mail Order Cost Sharing
Up to 30 days Up to 60 days Up to 100 days Tier 1 (Preferred Generic) $0 copay $0 copay $0 copay Tier 2 (Generic) $0 copay $0 copay $0 copay Tier 3 (Preferred Brand) $40 copay
($35 copay for Part D covered insulin)$80 copay
($70 copay for Part D covered insulin)Preferred Retail $120 copay
($105 copay for Part D covered insulin; Mail order $95 copay for Part D covered insulin)Tier 4 (Non-Preferred Drug) $100 copay $200 copay $300 copay Tier 5 (Specialty Tier) 33% of total Not covered Not covered -
Standard Retail Cost Sharing
Up to 30 days Up to 60 days Up to 100 days Tier 1 (Preferred Generic) $16 copay $32 copay $48 copay Tier 2 (Generic) $20 copay $40 copay $60 copay Tier 3 (Preferred Brand) $47 copay
($35 copay for Part D covered insulin)$94 copay
($70 copay for Part D covered insulin)$141 copay
($105 copay for Part D covered insulin)Tier 4 (Non-Preferred Drug) $100 copay $200 copay $300 copay Tier 5 (Specialty Tier) 33% of total Not covered Not covered -
Medicare Part D benefit stages
Stage 1: This stage only applies to plans with a Part D deductible. You stay in this stage until you have met your Part D deductible for your Tier 3, 4, and 5 drugs.
Stage 2: You stay in this stage until your out-of-pocket costs reach $2,100, then you move to Stage 3.
Stage 3: Also known as Catastrophic Coverage. In this stage, you pay nothing for your covered Part D drugs.
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Participating Pharmacies
With thousands of pharmacies nationwide, we've got a pharmacy that's close to your home.
Explore our provider and pharmacy directory to search for a participating in-network pharmacy near you. To learn more about our formularies or more about our prescription drug coverage click here.
The Formulary and/or pharmacy network may change at any time. You will receive notice when necessary.
Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. Call Customer Service for more information.
Important Message About What You Pay for Insulin - You won’t pay more than $35 or 25% coinsurance, whichever is less, for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.
Page current as of: 10/1/2025