** Cost ** |
Premium and Other Important Information |
$155 monthly plan premium in addition to your monthly Medicare Part B premium. |
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. |
Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept 'assignment' from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare 'assignment ' your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare 'limiting charge.' If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare 'limiting charge' does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to 'assignment' and 'limiting charges' that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.gov/physician or www.medicare.gov/supplier. You can also call 1-800 |
$2 500 out-of-pocket limit. All plan services included. |
$2 500 out-of-pocket limit. All plan services included. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. |
** Extra Benefits ** |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
This plan does not cover supplemental routine transportation. |
** Important Information ** |
Premium and Other Important Information |
$155 monthly plan premium in addition to your monthly Medicare Part B premium. |
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. |
Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept 'assignment' from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare 'assignment ' your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare 'limiting charge.' If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare 'limiting charge' does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to 'assignment' and 'limiting charges' that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.gov/physician or www.medicare.gov/supplier. You can also call 1-800 |
$2 500 out-of-pocket limit. All plan services included. |
$2 500 out-of-pocket limit. All plan services included. |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. |
** Inpatient Care ** |
Inpatient Hospital Care |
No limit to the number of days covered by the plan each hospital stay. |
For Medicare-covered hospital stays: |
Days 1 - 6: $150 copay per day |
Days 7 - 90: $0 copay per day |
$0 copay for each additional hospital day. |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
For hospital stays: |
Days 1 - 6: $200 copay per day |
Days 7 and beyond: $0 copay per day |
Inpatient Mental Health Care |
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. |
For Medicare-covered hospital stays: |
Days 1 - 6: $150 copay per day |
Days 7 - 90: $0 copay per day |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
For hospital stays: |
Days 1 - 6: $200 copay per day |
Days 7 and beyond: $0 copay per day |
Skilled Nursing Facility (SNF) |
Authorization rules may apply. |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
For SNF stays: |
Days 1 - 20: $0 copay per day |
Days 21 - 100: $50 copay per day |
For each SNF stay: |
Days 1 - 20: $0 copay per SNF day |
Days 21 - 100: $50 copay per SNF day |
Home Health Care |
$0 copay for Medicare-covered home health visits |
10% of the cost for home health visits |
Hospice |
You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice. |
** Outpatient Care ** |
Doctor Office Visits |
$10 copay for each primary care doctor visit for Medicare-covered benefits. |
$25 copay for each in-area network urgent care Medicare-covered visit |
$10 copay for each specialist visit for Medicare-covered benefits. |
$25 copay for each primary care doctor visit |
$25 copay for each specialist visit |
Chiropractic Services |
$10 copay for each Medicare-covered visit |
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. |
$25 copay for chiropractic benefits. |
Podiatry Services |
$10 copay for each Medicare-covered visit |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
$25 copay for podiatry benefits. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$10 copay for each Medicare-covered individual therapy visit |
$10 copay for each Medicare-covered group therapy visit |
$10 copay for each Medicare-covered individual therapy visit with a psychiatrist |
$10 copay for each Medicare-covered group therapy visit with a psychiatrist |
$0 copay for Medicare-covered partial hospitalization program services |
$25 copay for Mental Health benefits with a psychiatrist |
$25 copay for Mental Health benefits |
$0 copay for partial hospitalization program services |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$10 copay for Medicare-covered individual visits |
$10 copay for Medicare-covered group visits |
$25 copay for outpatient substance abuse benefits. |
Outpatient Services/Surgery |
Authorization rules may apply. |
$115 copay for each Medicare-covered ambulatory surgical center visit |
$115 copay for each Medicare-covered outpatient hospital facility visit |
$215 copay for outpatient hospital facility benefits. |
$215 copay for ambulatory surgical center benefits. |
Ambulance Services |
$100 copay for Medicare-covered ambulance benefits. |
$100 copay for ambulance benefits. |
Emergency Care |
$50 copay for Medicare-covered emergency room visits |
Worldwide coverage. |
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit. |
Urgently Needed Care |
$25 copay for Medicare-covered urgently-needed-care visits |
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the urgently-needed-care visit. |
Outpatient Rehabilitation Services |
$10 copay for Medicare-covered Occupational Therapy visits |
$10 copay for Medicare-covered Physical and/or Speech and Language Therapy visits |
$25 copay for Physical and/or Speech and Language Therapy visits |
$25 copay for Occupational Therapy benefits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
10% of the cost for Medicare-covered items |
20% of the cost for durable medical equipment |
Prosthetic Devices |
Authorization rules may apply. |
10% of the cost for Medicare-covered items |
20% of the cost for prosthetic devices. |
Diabetes Programs and Supplies |
$0 copay for Diabetes self-management training |
$0 copay for: |
Diabetes monitoring supplies |
Therapeutic shoes or inserts |
If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of $10 may apply |
$0 to $25 copay for Diabetes self-management training |
$0 copay for Diabetes monitoring supplies |
$0 copay for Therapeutic shoes or inserts |
If the doctor provides you services in addition to (Outpatient Diagnostic Procedures/Tests/Lab Services Diabetes Self-Management Training) separate cost sharing of $25 may apply |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
Authorization rules may apply. |
$0 to $10 copay for Medicare-covered lab services |
$0 to $10 copay for Medicare-covered diagnostic procedures and tests |
$0 to $10 copay [or 10% of the cost] for Medicare-covered X-rays |
$0 to $10 copay [or 10% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays) |
$0 to $10 copay [or 10% of the cost] for Medicare-covered therapeutic radiology services |
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $10 may apply |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $10 may apply |
10% of the cost for therapeutic radiology services |
10% of the cost for outpatient X-rays |
10% of the cost for diagnostic radiology services |
$0 to $25 copay for diagnostic procedures tests and lab services |
If the doctor provides you services in addition to (Outpatient Diagnostic Procedures/Tests/Lab Services Diabetes Self-Management Training) separate cost sharing of $25 may apply |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
Authorization rules may apply. |
$10 copay for Medicare-covered Cardiac Rehabilitation Services |
$10 copay for Medicare-covered Intensive Cardiac Rehabilitation Services |
$10 copay for Medicare-covered Pulmonary Rehabilitation Services |
$25 copay for Cardiac Rehabilitation Services |
$25 copay for Intensive Cardiac Rehabilitation Services |
$25 copay for Pulmonary Rehabilitation Services |
Preventive Services and Wellness/Education Programs |
$0 copay for all preventive services covered under Original Medicare at zero cost sharing: Abdominal Aortic Aneurysm screening Bone Mass Measurement Cardiovascular Screening Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam) Colorectal Cancer Screening Diabetes Screening Influenza Vaccine Hepatitis B Vaccine HIV Screening Breast Cancer Screening (Mammogram) Medical Nutrition Therapy Services Personalized Prevention Plan Services (Annual Wellness Visits) Pneumococcal Vaccine Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only) Smoking Cessation (Counseling to stop smoking) Welcome to Medicare Physical Exam (Initial Preventive Physical Exam) |
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Please contact plan for details. |
The plan covers the following supplemental education/wellness programs: |
Written health education materials including Newsletters |
Nutritional benefit |
Health Club Membership/Fitness Classes |
Nursing Hotline |
$0 copay for Medicare-covered preventive services |
$0 copay for supplemental preventive services |
$0 copay for supplemental education/wellness programs |
Kidney Disease and Conditions |
Authorization rules may apply. |
10% of the cost for renal dialysis |
$0 copay for kidney disease education services |
$0 copay for kidney disease education services |
10% of the cost for renal dialysis |
Outpatient Prescription Drugs |
10% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
10% of the cost for Part B drugs out-of-network. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.providencehealthplan.com on the web. |
Different out-of-pocket costs may apply for people who have limited incomes live in long term care facilities or have access to Indian/Tribal/Urban (Indian Health Service) providers. |
The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). |
Total yearly drug costs are the total drug costs paid by both you and a Part D plan. |
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. |
Some drugs have quantity limits. |
Your provider must get prior authorization from Providence Medicare Open + RX (PPO) for certain drugs. |
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. |
You pay $0 the first time you fill a prescription for certain drugs. These drugs will be listed as 'free first fill' on the plan?s website formulary printed materials and on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If you request a formulary exception for a drug and Providence Medicare Open + RX (PPO) approves the exception you will pay Tier 3: Specialty Tier Drugs cost sharing for that drug. |
$0 deductible. |
You pay the following until total yearly drug costs reach $2 930: |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$7 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy |
$50 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy |
33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy |
$21 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy |
$150 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy |
$10 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy |
$50 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy |
33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy |
$30 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy |
$150 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$10 copay for a one-month (34-day) supply of drugs in this tier |
$50 copay for a one-month (34-day) supply of drugs in this tier |
33% coinsurance for a one-month (34-day) supply of drugs in this tier |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$7 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. |
$50 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. |
33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. |
$21 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. |
$150 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. |
$10 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. |
$50 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. |
33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. |
$30 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. |
$150 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. |
After your total yearly drug costs reach $2 930 you receive a discount on brand name drugs and pay 86% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 700. |
Tier 3: Specialty Tier Drugs |
After your yearly out-of-pocket drug costs reach $4 700 you pay the greater of: 5% coinsurance or $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs. |
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Providence Medicare Open + RX (PPO). |
You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 930: |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$10 copay for a one-month (30-day) supply of drugs in this tier |
$50 copay for a one-month (30-day) supply of drugs in this tier |
33% coinsurance for a one-month (30-day) supply of drugs in this tier |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700. You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 700. |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
After your yearly out-of-pocket drug costs reach $4 700 you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share which is the greater of: 5% coinsurance or $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs. |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
Tier 3: Specialty Tier Drugs |
Dental Services |
Authorization rules may apply. |
In general preventive dental benefits (such as cleaning) not covered. |
$10 copay for Medicare-covered dental benefits |
$25 copay for comprehensive dental benefits |
Hearing Services |
In general supplemental routine hearing exams and hearing aids not covered. |
$10 copay for Medicare-covered diagnostic hearing exams |
$25 copay for hearing exams. |
** Additional Benefits ** |
Vision Services |
$0 copay for one pair of eyeglasses or contact lenses after cataract surgery |
$0 copay for exams to diagnose and treat diseases and conditions of the eye. |
$10 copay for up to 1 supplemental routine eye exam(s) every two years |
$0 to $25 copay for eye exams. |
$0 copay for eye wear. |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
This plan does not cover supplemental routine transportation. |
Acupuncture |
This plan does not cover Acupuncture. |
** Inpatient Care ** |
Inpatient Hospital Care |
No limit to the number of days covered by the plan each hospital stay. |
For Medicare-covered hospital stays: |
Days 1 - 6: $150 copay per day |
Days 7 - 90: $0 copay per day |
$0 copay for each additional hospital day. |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
For hospital stays: |
Days 1 - 6: $200 copay per day |
Days 7 and beyond: $0 copay per day |
** Outpatient Care ** |
Doctor Office Visits |
$10 copay for each primary care doctor visit for Medicare-covered benefits. |
$25 copay for each in-area network urgent care Medicare-covered visit |
$10 copay for each specialist visit for Medicare-covered benefits. |
$25 copay for each primary care doctor visit |
$25 copay for each specialist visit |
Outpatient Services/Surgery |
Authorization rules may apply. |
$115 copay for each Medicare-covered ambulatory surgical center visit |
$115 copay for each Medicare-covered outpatient hospital facility visit |
$215 copay for outpatient hospital facility benefits. |
$215 copay for ambulatory surgical center benefits. |
Ambulance Services |
$100 copay for Medicare-covered ambulance benefits. |
$100 copay for ambulance benefits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
10% of the cost for Medicare-covered items |
20% of the cost for durable medical equipment |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
Authorization rules may apply. |
$0 to $10 copay for Medicare-covered lab services |
$0 to $10 copay for Medicare-covered diagnostic procedures and tests |
$0 to $10 copay [or 10% of the cost] for Medicare-covered X-rays |
$0 to $10 copay [or 10% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays) |
$0 to $10 copay [or 10% of the cost] for Medicare-covered therapeutic radiology services |
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $10 may apply |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $10 may apply |
10% of the cost for therapeutic radiology services |
10% of the cost for outpatient X-rays |
10% of the cost for diagnostic radiology services |
$0 to $25 copay for diagnostic procedures tests and lab services |
If the doctor provides you services in addition to (Outpatient Diagnostic Procedures/Tests/Lab Services Diabetes Self-Management Training) separate cost sharing of $25 may apply |
** Additional Benefits ** |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
This plan does not cover supplemental routine transportation. |