2020 Medicare Advantage Plan Comparison - Providence ...

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2020 Medicare Advantage Plan Comparison - Providence ...
2020 Medicare
Advantage Plan
Comparison

Providence   Medicare   Timber + Rx (HMO)
Providence   Medicare   Bridge 2 + Rx (HMO)
Providence   Medicare   Choice + Rx 002 (HMO-POS)
Providence   Medicare   Extra + Rx 002 (HMO)
Service area:
Columbia, Lane, Marion, Polk counties in Oregon, and Clark County in Washington

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Why choose
Providence?
Medicare choices can be confusing. So we’re here to make it easier.
Providence Medicare Advantage Plans support you every step of the way.
You’re covered, whenever and wherever you need care. Plus, you'll get
extra features and convenient tools to help you live well.

   Variety of plans and options
   We designed our plans with your needs and budget in mind with different plan types and
   cost sharing options (deductibles, coinsurance and copayments), there's a plan for everyone.

   Broad network
   With access to thousands of network providers, you'll find quality care when you need it.

   Care for you and the community
   We care about the total well-being of each person we serve. That’s why we donate vital
   health care services that support the issues and challenges of our local communities.

   Experience and innovation
   We're part of Providence St. Joseph Health so you benefit from more than 160 years of
   health care experience and innovation. With our broad resources, you'll get modern
   conveniences, like telemedicine, and integrated systems that make it simpler for you
   to get the very best care possible.

Providence Medicare Advantage Plans is an HMO, HMO-POS and HMO SNP with Medicare and Oregon
Health Plan contracts. Enrollment in Providence Medicare Advantage Plans depends on contract renewal.

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2020 Providence Medicare
     Service Area Map
             + Timber + Rx (HMO)
             + Bridge 2 + Rx (HMO)
             + Choice + Rx 002 (HMO-POS)
             + Extra + Rx 002 (HMO)

                                          Additional plans are available in the area.
                                          Visit ProvidenceHealthAssurance.com
                                          for more information.

                    Columbia
                                  Clark

          Polk           Marion

                                  Lane

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Benefits and services
beyond Original Medicare
Put all the perks of Providence Medicare Advantage Plans to work for you. From
achieving better health and fitness to accessing coaching and support, our plans
bring these extras and more:

         Annual routine eye exam                                Providence Express Care
         offered on all plans and an allowance                  Virtual and Express Care
         for prescription glasses, frames and/or                no-cost, on-demand provider visits from
         contacts on some plans.                                your computer or smartphone, or visit one
                                                                of our Express Care clinics for same-day
         Annual routine hearing exam                            care in many locations.
         and hearing aid benefit
         provides you with high-quality                         Health coaching
         hearing aids and local professional                    can help you lose weight,
         care at a fraction of the cost.                        increase your physical activity or
                                                                just feel better when you join
         No-cost fitness                                        the 92 percent of Providence health
         center membership                                      coaching participants who’ve
                                                                made a lifestyle improvement.
         so you can work out your way, or
         even work out at home using
         two home-fitness kits per year.                        myProvidence
                                                                so you can access a summary
         24/7 nurse advice                                      of your benefits, view claims,
         so you can connect with                                pay your premium and get
         registered nurses day or night                         prescription drug information.
         with no cost to you.
                                                                Savings and assistance
         Optional home assessments                              with My Advocate®

         with licensed, board-certified nurses.                 which connects members
                                                                with a variety of government
                                                                and community programs.

Health coaching visits limited to 12 per calendar year. Providence Medicare Advantage Plans is an
HMO, HMO-POS and HMO SNP with Medicare and Oregon Health Plan contracts. Enrollment in
Providence Medicare Advantage Plans depends on contract renewal.

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Providence Medicare Advantage Plans – Part C
                                          Providence Medicare                Providence Medicare
                                           Timber + Rx (HMO)                 Bridge 2 + Rx (HMO)
 Monthly premium
 with prescription                                  $0                                 $40
 drug coverage
                                               In-network                          In-network
 Medical deductible                                 $0                                 $0
 Out-of-pocket maximum                            $5,500                             $4,900
                Benefits                         You pay                            You pay
 Doctor office visit (PCP)                          $0                                 $0

 Specialist visit                                  $40                                 $35

 Preventive care                                    $0                                 $0
                                           Days 1-4: $450/day                  Days 1-6: $325/day
 Inpatient hospital
                                        Day 5 and beyond: $0/day            Day 7 and beyond: $0/day
                                              Days 1-20: $0                       Days 1-20: $0
 Skilled nursing facility
                                         Days 21-100: $172/day               Days 21-100: $160/day
 Outpatient surgery                               $450                                $375
 Diabetic supplies                               $0 – 20%                           $0 – 20%
 Lab                                                $0                                 $0
 X-ray                                              $15                                $10
 Outpatient diagnostic tests
                                                    $0                                 $0
 and procedures
                                               $20-$40;                            $20-$35;
 Alternative care
                                         $500 annual maximum                 $500 annual maximum
 Therapy: PT, OT, ST                               $40                                 $35
 Durable medical
                                                   20%                                 20%
 equipment
 Chiropractic                                      $20                                 $20
 Home health                                        $0                                 $0
 Secure video visits                                $0                                 $0
 No-cost fitness center
                                                    $0                                 $0
 membership included
 Preventive dental                                 $15                                 $15
                                          Worldwide coverage                  Worldwide coverage
 Urgent care                                       $50                                 $50
 Emergency room                                    $90                                 $90
 Ambulance (air/ground)                    $50 – $250 one way                  $50 – $250 one way

See your Evidence of Coverage for more information. Out-of-network/non-contracted providers are under no
obligation to treat Providence Medicare Advantage Plans members, except in emergency situations. Please
call our customer service number or see your Evidence of Coverage for more information, including the cost
sharing that applies to out-of-network services.

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Providence Medicare Advantage Plans – Part C
                    Providence Medicare                                Providence Medicare
                 Choice + Rx 002 (HMO-POS)                             Extra + Rx 002 (HMO)

                              $88                                                $173

          In-network                    Out-of-network                       In-network
               $0                              $0                                $0
             $4,500                    $10,000 combined                        $3,400
                            You pay                                            You pay
               $15                            $25                                $0

              $30                             $50                                $20

               $0                             30%                                $0
      Days 1-6: $300/day                                                 Days 1-5: $250/day
                                              30%
   Day 7 and beyond: $0/day                                           Day 6 and beyond: $0/day
         Days 1-20: $0                                                      Days 1-20: $0
                                              30%
     Days 21-100:$160/day                                              Days 21-100: $150/day
             $250                             30%                               $150
            $0 – 20%                          30%                             $0 – 20%
               $0                             30%                                $0
               $15                            30%                                $0

               $0                             30%                                $0

          No coverage                     No coverage                        No coverage

              $30                             30%                                $20

              20%                             30%                                20%

              $20                             30%                                $20
               $0                             30%                                $0
               $0                         No coverage                            $0

               $0                         No coverage                            $0

          No coverage                     No coverage                            $15
                       Worldwide coverage                               Worldwide coverage
              $50                             $50                                $50
              $90                             $90                                $70
      $50 – $250 one way              $50 – $250 one way                 $50 – $250 one way

Other charges and limits may apply.

Providence Medicare Advantage Plans is an HMO, HMO-POS and HMO SNP with Medicare and Oregon
Health Plan contracts. Enrollment in Providence Medicare Advantage Plans depends on contract renewal.

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Pharmacy coverage – Part D
                             Providence      Providence          Providence Medicare     Providence
                          Medicare Timber Medicare Bridge          Choice + Rx 002    Medicare Extra
                             + Rx (HMO)     2 + Rx (HMO)              (HMO-POS)       + Rx 002 (HMO)
                          $270 (waived on  $200 (waived on         $240 (waived on     $0 (waived on
 Annual deductible††
                            generic tiers)  generic tiers)           generic tiers)     generic tiers)
                          30-day 90-day 30-day 90-day             30-day      90-day 30-day 90-day
 Preferred generic          $0      $0         $0        $0          $4           $8          $0         $0
 Generic                    $10     $10       $10        $10         $13        $31.20       $10         $10
 Preferred brand            $47     $141      $47        $141       $47         $112.80      $45      $90

 Non-preferred drugs       $100     $300     $100       $300        $100         $240        $90      $180

 Specialty drugs           28%      N/A       29%        N/A        28%           N/A        33%         N/A
 Deductible is waived on all generic tiers (Tiers 1 and 2).
††

 Copays listed are for Preferred Network pharmacies only; other pharmacy copays may cost more.
For Extra + Rx 002 (HMO), your Phase 2 coverage gap cost share for preferred generic drugs at a Preferred
Network pharmacy or mail-order pharmacy will be $0. All other cost shares will be 25%.

             Initial coverage                   Coverage gap                    Catastrophic coverage
                  Phase 1                          Phase 2                                Phase 3
     When the total paid by you       You pay only 25% of the costs of      You pay whichever of these is
     and the plan reaches $4,020,     brand-name drugs and 25% of the       larger: either 5% coinsurance
     Phase 2 begins.                  costs of generic drugs. You stay in   for the costs of the drug or
                                      this stage until your out-of-pocket   $3.60 copay for generic drugs;
                                      costs reach $6,350. After that,       $8.95 copay for brand-name or
                                      Phase 3 begins.                       specialty drugs.

Vision coverage – included at no extra charge
                            Providence       Providence      Providence Medicare     Providence
                          Medicare Timber Medicare Bridge      Choice + Rx 002     Medicare Extra
                            + Rx (HMO)      2 + Rx (HMO)         (HMO-POS)        + Rx 002 (HMO)
                             Up to $75                            Up to $75
 Routine eye exams                       Up to $75 allowance                     Up to $75 allowance
                             allowance                            allowance
 Prescription
                         $100 allowance        $150 allowance        $220 allowance         $215 allowance
 eyeglasses
                             per year             per year              per year               per year
 or contact lenses
You are responsible for any cost above the allowance for routine eye exams, prescription eyeglasses or
contact lenses.
Hearing coverage – included at no extra charge
                             Providence         Providence       Providence Medicare            Providence
                           Medicare Timber    Medicare Bridge      Choice + Rx 002            Medicare Extra
                             + Rx (HMO)        2 + Rx (HMO)           (HMO-POS)               + Rx 002 (HMO)
                                                                           $0
 Routine hearing
                               $0               $0 copay            out-of-network:                 $0
 exam (one per year)
                                                                      not covered
 Hearing aids                                                        $699 – $999
                        $499 – $799 per      $399 – $699 per        per hearing aid            $499 – $799
 (up to two hearing
                           hearing aid         hearing aid          out-of-network:           per hearing aid
 aids per year)                                                       not covered
You must see a TruHearing provider. Other charges and limits may apply.
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2020 Optional Supplemental Dental Benefits
  Plans that include
                                                    Bridge 2 + Rx, Extra + Rx 002, Timber + Rx
  Wrap options:

                                                  Basic Wrap                         Enhanced Wrap

  Monthly premium                                    $29.40                                $42.20
                                       In-network    Out-of-network           In-network    Out-of-network
  Plan benefits                          member         member                  member         member
                                      responsibility responsibility*         responsibility responsibility*
  Office visit copay                               No copay                              No copay
  Annual deductible    1
                                            $50                 $150               $50                $150
  Annual maximum                                     $1,000                                $1,500
  Waiting periods                                    None                                   None
  Provider network                           Any licensed dentist2                 Any licensed dentist2
  Out-of-network reimbursement            Maximum allowable charge              Maximum allowable charge
  Diagnostic and Preventive Services
  Oral examinations3                         0%                 20%                0%                 20%
  Bitewing X-rays  4
                                             0%                 20%                0%                 20%
  Panoramic and other
                                             0%                 20%                0%                 20%
  diagnostic X-rays5
  Comprehensive Dental Services
  Basic fillings and simple
                                            50%                 60%                50%                60%
  extractions
  Dentures6                                 50%                 60%                50%                60%
  Crowns and bridges7                       50%                 60%                50%                60%
  Oral surgery                                    Not covered                      50%                60%
  Endodontics (root canals)                       Not covered                      50%                60%
  Periodontics                                    Not covered                      50%                60%

*Important notes: Out-of-network dentists may charge more than the amount allowed by Providence Medicare
 Advantage Plans. If this happens, they may send members a "balance bill" for the difference between their
 charged amount and the amount paid by the plan.
 1
   Deductibles are waived for diagnostic and preventive services
 2
   Seeking care from a participating in-network dentist will reduce out-of-pocket costs and prevent a balance bill
 3
   Oral examinations – limited to one per calendar year
 4
   Bitewing or Periapical X-rays – limited to one bitewing and two periapical per calendar year
 5
   Panoramic or other diagnostic X-rays – limited to one per five years
 6
   $250 lifetime denture benefit
 7
   Crown/bridge max. (Basic) – $100 per tooth per year; crown/bridge max. (Enhanced) – $500 per year

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2020 Optional Supplemental Dental Benefits
  Plans that include
                                                                   Choice + Rx 002
  Basic or Enhanced option:

                                                      Basic                               Enhanced

  Monthly premium                                    $33.70                                $46.50
                                        In-network    Out-of-network           In-network    Out-of-network
  Plan benefits                           member         member                  member         member
                                       responsibility responsibility*         responsibility responsibility*
  Office visit copay                                No copay                              No copay
  Annual deductible    1
                                             $50                 $150               $50                $150
  Annual maximum                                     $1,000                                 $1,500
  Waiting periods                                     None                                  None
  Provider network                            Any licensed dentist2                 Any licensed dentist2
  Out-of-network reimbursement            Maximum allowable charge               Maximum allowable charge
  Diagnostic and Preventive Services
  Oral examinations3                         0%                  20%                0%                 20%
  Semiannual teeth cleaning    4
                                             0%                  20%                0%                 20%
  Bitewing X-rays5                           0%                  20%                0%                 20%
  Full, panoramic and other
                                             0%                  20%                0%                 20%
  diagnostic X-rays6
  Comprehensive Dental Services
  Basic fillings and simple
                                            50%                  60%               50%                 60%
  extractions
  Dentures7                                 50%                  60%               50%                 60%
  Crowns and bridges8                       50%                  60%               50%                 60%
  Oral surgery                                     Not covered                     50%                 60%
  Endodontics (root canals)                        Not covered                     50%                 60%
  Periodontics                                     Not covered                     50%                 60%

*Important notes: Out-of-network dentists may charge more than the amount allowed by Providence Medicare
 Advantage Plans. If this happens, they may send members a "balance bill" for the difference between their
  charged amount and the amount paid by the plan.
 1
   Deductibles are waived for diagnostic and preventive services
 2
   Seeking care from a participating in-network dentist will reduce out-of-pocket costs and prevent a balance bill
 3
   Oral examinations – limited to two per calendar year
 4
   Teeth cleanings (prophylaxis: cleaning and polishing teeth) – limited to two per calendar year
 5
   Bitewing or Periapical X-rays – limited to two per calendar year
 6
   Full, panoramic or other diagnostic X-rays – limited to one per five years
 7
   $250 lifetime denture benefit
 8
   Crown/bridge max. (Basic) – $100 per tooth per year; crown/bridge max. (Enhanced) – $500 per year

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Our Mission
  As expressions of God’s healing love, witnessed through the ministry of Jesus,
  we are steadfast in serving all, especially those who are poor and vulnerable.

  Our Values
  Compassion        |   Dignity   |   Justice   |   Excellence   |   Integrity

Call us for information, to enroll, or to make a personal appointment at
866-948-4985 8 a.m. to 8 p.m. (Pacific Time),
seven days a week (Oct. 1 – Dec. 7); Monday – Friday (Dec. 8 – Sept. 30)

Enroll online at ProvidenceHealthAssurance.com

Providence Health & Services, a not-for-profit health system, is an equal opportunity organization in
the provision of health care services and employment opportunities.
© 2019 Providence Health Plan. All rights reserved.

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