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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
    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.



    2022

    Benefit summaries


    Summaries of Benefits and Coverage



    2021

    Benefit summaries


    Summaries of Benefits and Coverage



    2020

    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 Swedish may contribute to the account.

    More information about your health plan can be found in the Summary Plan Description located on the HR portal under Find HR Information/Benefits/Resources & Notices.

  • Pharmacy resources
    Formulary

    Providence Health Plan provides a comprehensive prescription drug formulary designed to promote safe, effective and affordable drug therapy.


    2022 plans formulary

    2021 plans formulary


    Tips to help you save when you 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
    Tip 1: Use your preventive care benefits

    Your plan covers certain preventive services (PDF) 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 Swedish medical plan member, you receive higher coverage if you receive care from a Swedish, Providence, PacMed, Minor & James Medical, Polyclinic, CHI Franciscan or other Providence-Swedish Health Alliance ACO network 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: Receive care from 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.



    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.

    Purchase up to a 90-day supply of maintenance drugs from a preferred retail or mail-order pharmacy. Not all drugs are considered maintenance prescriptions, including compounded drugs, drugs from specialty pharmacies and oncology drugs. Learn more about this here.



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

    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. Learn about prior authorization in the Prior authorization section on this page.

  • Discounts and wellness resources
    Hearing aid discounts

    TruHearing provides members (including parents and grandparents) 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.
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