Need help?

Hey!

You are now leaving the Providence Medicare Advantage Plans website. Are you sure thats what youd like to do?

No, I'll stay Yes, I'm leaving

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
    Member ID card

    Carry your member ID card with you as you’ll need it when you receive services. It includes important information, including your name, member ID number, medical plan, network information and important phone numbers.



    Benefit summaries


    Summaries of Benefits and Coverage


    These materials do not describe the savings account associated with the medical plan nor do they list the possible financial incentive that PacMed may contribute to the account.

    For more information about your benefits, visit HRforCaregivers.org.

    More information about your health plan can be found in the Summary Plan Description located on the HR Service Portal. Enter “SPD” in the search bar.

  • 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. You can purchase up to a 90-day supply.
    • 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

    Website: www.ppsrx.com
    503-797-2100 or 800-552-6694
    Monday to 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.

  • Making the most of your benefits
    The following tips can help you stay well and save on health care costs.

    Tip 1: Use your preventive care benefits
    Your plan covers certain preventive services in full when received from an in-network provider.

    Tip 2: Choose in-network providers and pharmacies
    Refer to the online provider directory to locate in-network providers and participating pharmacies.

    Tip 3: Use preferred retail or mail order pharmacies to fill 90-day supplies of maintenance medication
    Purchase up to a 90-day supply of maintenance medications using a participating mail-order pharmacy or a preferred retail pharmacy. Not all drugs are considered maintenance prescriptions, including compounded drugs, drugs from specialty pharmacies and oncology drugs. Learn more about this in the pharmacy resources section of this page.

    Tip 4: Access the most appropriate care

    Knowing when and where to get care is essential to your health and your wallet.

    Learn about your care options here.

    Tip 5: Compare costs
    Before receiving care, log in to myProvidence and use the treatment cost calculator to learn about a facility or doctor, and the estimated costs of your treatment. You can also compare medical facilities to make sure you’re getting the best care at the best price. The costs are customized to you based on your plan benefits, the providers in your plan’s network and how much you’ve accumulated toward your deductible and out-of-pocket maximum.

  • Discounts and wellness resources
    Extra values and discounts

    You can enjoy many perks when you’re enrolled in a Providence Health Plan. Here are just a few extras values and discounted services just for members.

    ProvRN offers 24/7 medical advice from registered nurses who can evaluate your symptoms to help determine your next steps for care. Exclusive to Providence Health Plan members, it's free and available when you need it. Contact ProvRN by phone at 503-574-6520 or 800-700-0481 (TTY: 711).

    LifeBalance offers savings on health club memberships, fitness classes, massage therapy, weight loss programs, recreational, cultural and wellness events, family activities, movies, travel and more. Log in or register for a free myProvidence account to access discounts through LifeBalance. 

    TruHearing
     provides members (including parents and grandparents) with significant discounts on digital hearing aids. The TruHearing program includes a free hearing screening, 45-day money-back guarantee, three-year warranty, one-year supply of batteries and 12 months of no-interest financing upon approved credit. This program is not a covered benefit under your medical health plan, but is an employee extra value service. Visit www.truhearing.com or call TruHearing at 877-253-4040 to find the nearest provider.



    Wellness resources

    Smoking cessation
    Smoking is a powerful addiction. Quitting takes practice, patience and support. You can get the help you need with one of our 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 1-800-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.
Contact customer service

We’re here for you.

Reach out to us for help. We're happy to answer your questions or to assist you in finding the resources you need.

Get in touch