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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 resource guide

    The guide is a single resource you can use to take an active role in your health and engage with your health plan. It provides useful information about myProvidence, care options, and other programs available for PHP members. 

    View or download

  • 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.

    2024 Benefit Summaries

    High Deductible Plan

    High Deductible Plan (VEBA) - includes Rx and massage

    Low Deductible Plan

    Massage Benefit

    (only applies to Premium and Choice plans)

    Pharmacy (Rx) Benefit

    (only applies to Premium and Choice plans)

    2024 Summaries of Benefits and Coverage (SBCs)
  • Behavioral health resources

    We know behavioral health care isn’t a one-size-fits-all solution. We’re all unique, and our journey and needs vary depending on our personal situation. At Providence, we want that lens to drive us when looking at the mix of services and solutions we offer for your well-being. Whether you’re looking for some support to relax, ready to try self-directed therapy that helps you to engage when you feel like it, or looking for immediate connection to a provider – via text, voice, video or face to face – we have many options to fit your needs.

    Access now
  • Pharmacy resources

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


    2024 plan 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).
    • If you take an eligible specialty medication, the Smart RxAssist program helps lower your out-of-pocket costs to $0.
      • The list of medications eligible for this program is available here.
      • There is no cost to you for participating in the Smart RxAssist program.
      • You are automatically enrolled in the program if you take an eligible specialty medication in the Smart RxAssist program.
      • If you are filling an eligible medication in the Smart RxAssist program, a Patient Advocate may reach out to you to complete program enrollment.
      • Medications eligible for the program are subject to change.
      • Because this program provides a $0 cost not subject to the deductible, the tax laws regarding a health savings account make this program unavailable to those enrolled in the Health Savings Account (HSA) medical plan.

    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

    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 (Carelon Medical Benefits Management (formerly American Imaging Management) authorizes these services; contact Carelon at 800-920-1250)

      • Effective March 1, 2023, American Imaging Management/AIM Specialty Health and Beacon Health Options changed their names to Carelon. AIM transitioned to Carelon Medical Benefits Management, and Beacon Health Options transitioned to Carelon Behavioral Health. If you have questions about this change, please call 800-878-4445 or click here to learn more.
    • 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)
    • Outpatient Rehab for Physical and Occupational Therapy: 866-803-8052
    • 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
    • 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 contact PHP customer service at 800-878-4445.

    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. 

    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.
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