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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
    Benefit summaries


    Summaries of Benefits and Coverage

    These benefit summaries and SBCs do not describe the savings account associated with the medical plan nor do they list the possible financial incentive that Providence will contribute to the account if you choose to complete certain healthy activities by the given deadline. We encourage you to learn more about these types of savings accounts and what incentives may be available to you.

    More information about your health plan can be found in the Summary Plan Description located on the HR portal under the Resources tab.



    Seeing a specialist? Access care from select specialists and pay less out of pocket

    Under the Health Reimbursement or Health Savings medical plan, your out-of-pocket costs will be lower when care is provided by a Providence St. Joseph Health or affiliated specialist. To find a Providence St. Joseph Health or affiliated specialist:


    • Visit the online provider directory.
    • Search by member ID number for best results or enter as a visitor (click on browse by provider networks). If you enter as a visitor/browse by provider networks:

      • Under the Choose plan type drop down menu, select Specific employer groups.
      • Under Choose provider network, select your employer and region then Search.
      • Choose Find a care provider then Specialists.
      • Choose the type of specialist you need to see. 
      • On the right side of the Specialist Search Results page, check the Preferred Network (Tier 1) box and Update Filters.
  • Making the most of your benefits
    The following tips can help you save when you receive care:

    Tip 1: Use your preventive care benefits; certain services are covered in full. 

    Your plan covers certain preventive services in full when received from an in-network provider. 


    Tip 2: Access care from select specialists and receive a higher level of benefit.

    As a Providence Health Reimbursement or Health Savings medical plan member, you will receive higher coverage if you receive care from a Providence St. Joseph Health or affiliated specialist. 

    To find a Providence St. Joseph Health or affiliated specialist:


    • Visit the online provider directory.
    • Search by member ID number for best results or enter as a visitor (click on browse by provider networks). If you enter as a visitor/browse by provider networks:

      • Under the Choose plan type drop down menu, select Specific employer groups.
      • Under Choose provider network, select your employer and region then Search.
      • Choose "Find a care provider" then "Specialists".
      • Choose the type of specialist you need to see.
      • On the right side of the Specialist Search Results page, check the Preferred Network (Tier 1) box and Update Filters.


    Tip 3: Choose in-network providers and receive a higher level of benefit

    To find an in-network provider and access a wide range of services, visit the online provider directory. For the highest benefit, follow the instructions listed above to find the type of care you need. Providence Health Plan members in Eastern Washington can also access in-network care for select services from Group Health (PDF).



    Tip 4: Choose generic medications, use participating pharmacies and mail-order services, and have certain medications prior authorized.

    Use participating pharmacies to make the most of your pharmacy benefits. To find a participating pharmacy near you, search the online provider directory. If you prefer, call Providence Health Plan customer service at 800-878-4445, Monday through Friday, 8 a.m. to 5 p.m. to help locate a participating pharmacy or in-network provider. Plus, take advantage of additional pharmacy resources to help you save. You can find them below in the pharmacy resources section of this page.

    Purchase up to a 90-day supply of maintenance drugs 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.



    Tip 5: Know what services need to be authorized before you receive care.

    Certain services require a prior authorization, meaning that before you receive care, the service must be authorized by Providence Health Plan. Learn about prior authorization in the prior authorization section below on this page.

  • 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
  • Health and wellness resources

    Make the most of your health care benefits with discounts and online resources for managing costs, services and quality.

    Hearing aid discounts

    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.



    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.
  • Hearing aid benefit
    Save one of two ways

    Your health plan coverage may include a hearing aid benefit. Hearing aids are considered durable medical equipment and are subject to plan requirements such as medical necessity, deductible(s) and network requirements.

    Information about your plan coverage for durable medical equipment is included in your member materials. Your member materials are available online when you create and log into a free myProvidence account and are available under the member materials tab on this page.

    Providence Health Plan has partnered with TruHearing to provide members with affordable options for hearing aids.

    As a Providence Health Plan member, you also have access to discounts on hearing products and services through TruHearing. These discounts apply to products and services that are not covered under your health plan.

    Learn more

    To learn more about coverage for hearing aids and to locate a TruHearing provider, contact Providence Health Plan customer service at 503-574-7500 or 800-878-4455 (TTY: 711).

    Refer to a glossary of health insurance terms.

  • Nutritional counseling

    Tired of the weight roller coaster? Tired of trying the latest fad diet? Just tired of being tired? We hear you. Proper nutrition – a stable, consistent approach to it – is essential for peak body performance and preventing health concerns.

    Whether you're looking to lose weight, want to eat smarter, or battling an eating disorder, you and your dependents have access to nutritional counseling benefits. The first four visits are covered in full, meaning that you pay nothing out of pocket for these services. After your fourth visit, additional visits are paid according to your “office visits” benefit. See your member materials for your plan's benefits.



    Why nutritional counseling?

    We encourage you to fully understand and use your health plan benefits. When you access nutritional counseling services, you'll benefit from:


    • A personalized plan. You'll work with a nutrition counselor to develop a plan that works from where you are. Your needs will be thoroughly assessed and analyzed to develop a plan and pace that's right for you.
    • A healthier you. Proper nutrition and appropriate exercise will provide you enough energy to make it through each day. Without a proper diet and exercise level, you're at risk for health concerns.
    • Knowledge of foods that aren't scary and that taste good. Good nutrition isn't limited to bland, boring veggies. When you work with a nutrition counselor, you'll learn that there are foods that are not only good for you, but also taste good.


    Providence nutrition resources are available

    Regardless of where you live, Providence offers services that are close to home. Learn more about Providence's nutritional evaluation and counseling programs.




    Find the provider that's right for you

    Additional providers and programs are available. To find the provider that's right for you, search our online provider directory:


    • Visit our provider directory.
    • In the “Members” section, enter your member ID; select the orange “Go” button.
    • On the right side of the screen in the Provider Type drop down field, select “Specialists.”
    • In the “Specialty” field, select “Nutrition.”
    • Click the orange “GO” button.
    • You'll receive a list of providers who can help you with your health need.

    Make the most of your life, your health. Use your nutritional counseling benefits to help you stay well.

  • 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.

  • Use preventive care to stay well

    Maintain your good health for a lifetime. Sound too good to be true? Maybe. But, maybe not. The best approach to staying healthy for life is to prevent illness from ever beginning. Here are some tips to prevent illness:



    Prevention tip 1: Stay healthy with healthy habits every day

    • Sleep at least seven hours each night
    • Eat wholesome, nutrient-rich foods
    • Battle Your Exercise Excuses in whatever way, shape or form you choose; there are so many benefits
    • Laugh to improve your health
    • Enjoy sugar, salt and alcohol, if you want, but enjoy in moderation
    • Avoid tobacco and destructive substances by aspiring to be a quitter


    Prevention tip 2: Stay healthy by using your health plan's preventive care benefits

    Preventive care enables you to understand your health or potential health risks before a more serious health issue shows up. It's much easier – and far less expensive – to ward off health problems rather than to try to cure them once they show up. Preventive care may include physical exams, immunizations, laboratory tests and other types of screenings. Take a look at the preventive care that's covered in full by your health plan.

    Make the most of your life, your health. Use your preventive care benefits to help you stay well.

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