Providence Medicare Extra Part B Only + Rx (HMO)
Medicare Advantage Health Plan Details
Health insurance company offering plan: Providence Medicare Advantage Plans
- Rx
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $0 copay
Out-of-network: $20 copay
Out-of-network: $0 copay
Emergency Room
$125 copay
Ambulance Coverage
In-network: $50-$275 copay
Out-of-network: $50-$275 copay
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Lab services:
In-network: $0 copay
Out-of-network: $0 copay
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: 15% coinsurance
Out-of-network: 15% coinsurance
Outpatient x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Hospital Services
Outpatient hospital coverage:
In-network: $150 copay
Out-of-network: $150 copay
Rehabilitation Coverage
Occupational therapy services:
In-network: $20 copay
Out-of-network: $20 copay
Urgent Care Coverage
$125 copay
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $20 copay
Out-of-network: $20 copay
Outpatient individual therapy with a psychiatrist:
In-network: $20 copay
Out-of-network: $20 copay
Outpatient group therapy visits:
In-network: $20 copay
Out-of-network: $20 copay
Outpatient individual therapy visit:
In-network: $20 copay
Out-of-network: $20 copay
Dental, Vision, Hearing Benefits
Dental Services
Oral exams:
In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Vision Benefits
Routine eye exams:
In-network: $0 copay
Out-of-network: $0 copay
Hearing Benefits
Hearing exam:
In-network: $0 copay
Out-of-network: $0 copay
Fitting/evaluation:
In-network: $0 copay
Out-of-network: $0 copay
Hearing aids - prescription:
In-network: $499-$999 copay
Out-of-network: $499-$999 copay
Rx Drug Coverage - Preferred Retail Cost
Tier 1: Preferred Generic
$1.00 copay (30-day supply)
$2.40 copay (90-day supply)
Tier 2: Generic
$12.00 copay (30-day supply)
$28.80 copay (90-day supply)
Tier 3: Preferred Brand
$40.00 copay (30-day supply)
$120.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$90.00 copay (30-day supply)
$216.00 copay (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$12.00 copay (30-day supply)
$36.00 copay (90-day supply)
Tier 2: Generic
$20.00 copay (30-day supply)
$60.00 copay (90-day supply)
Tier 3: Preferred Brand
$47.00 copay (30-day supply)
$141.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$100.00 copay (30-day supply)
$300.00 copay (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$1.00 copay (30-day supply)
$2.40 copay (90-day supply)
Tier 2: Generic
$12.00 copay (30-day supply)
$28.80 copay (90-day supply)
Tier 3: Preferred Brand
$40.00 copay (30-day supply)
$120.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$90.00 copay (30-day supply)
$216.00 copay (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
Additional Added Benefits
Plan Links
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