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Providence Medicare Advantage Plans Comparison
This is only a brief comparison of benefits. For a complete Summary of Benefits, including premium and plan guidelines, please refer to the pre-enrollment packet provided by Providence Medicare Advantage Plans. Medicare coverage rules apply to the benefits listed below, for instance, you must continue to pay your Medicare Part B premium.
| With Prescription Drug Benefit |
Without Prescription Drug Benefit |
||
|---|---|---|---|
| Note: You must continue to pay your Medicare Part B premium. | |||
| Providence Medicare Extra + RX (HMO) |
Providence Medicare Choice + RX (HMOPOS) |
Providence Medicare Extra (HMO) |
Providence Medicare Choice (HMOPOS) |
| $117 | $58 | $92 | $32 |
| Providence Medicare Extra* (HMO) | Providence Medicare Choice (HMOPOS) | ||
|---|---|---|---|
| In-network benefit only | In-network | Out-of-network | |
| (A) Diagnostic testing copayment may apply. (B) Copayment waived if admitted within 24 hours for the same condition. (C) For office visits, other charges may apply. *You must use plan providers except in emergent or urgent care situations (or for out-of-area renal dialysis). If you obtain routine care from out-of-network providers neither Medicare nor Providence Medicare Advantage Plans will be responsible for the costs. |
|||
| You Pay | You Pay | ||
| Doctor Office Visit | $15 | $20 | $30 |
| Specialist Visit (Referral needed for PME and PMC In-Network providers) |
$15 | $20 | $30 |
| Lab | $0 | $0 | 20% |
| Xray | 10% | 10% | 20% |
| Outpatient Surgery | $100 | $150 | 20% |
| Routine Eye Exam Every 24 months (A) (no referral needed) | $15 | $20 | $30 (C) |
| Medical Eye Exam | $15 | $20 | $30 (C) |
| Annual Women’s Exam Pap, Pelvic, Mammogram (no referral needed) | $15 (A) | $20 (A) | $30 (C) |
| Mental Health & Chemical Dependency Counseling | $15 | $20 | 20% |
| Therapy: PT, OT, ST | $15 | $20 | 20% |
| Inpatient Hospital | $300 | $450 | 20% |
| Skilled Nursing Facility Day 1-20 Day 21-100 |
$0 $0 |
$0 $50/day |
20% 20% |
| Home Health Care | $0 | 10% | 20% |
| Durable Medical Equipment | 10% | 15% | 20% |
| Test strips and glucometers | $0 | $0 | 20% |
| Emergency Room (A) (World-wide Coverage) |
$50 (B) | $50 (B) | $50 (B) |
| Urgent Care (A) (World-wide Coverage) |
$25 (B) | $25 (B) | $25 (B) |
| Ambulance (World-wide) (Air or Ground) |
$100 | $100 | $100 |
| Out-of-pocket Maximum | $2,500 | $3,400 | |
| Initial Coverage | Coverage Gap | Catastrophic Coverage |
|---|---|---|
| Phase 1† Benefit Eligible |
Phase 2 No Benefit |
Phase 3‡ Benefits Restart, but at a different level |
| †72% of our members stay in Phase 1 | ‡4% of our members reach Phase 3 | |
| You Pay | You Pay | You Pay |
| $0 deductible $6 or $9 Generic drugs $45 Brand name drugs 33% Specialty drugs When the total paid by you and the plan reaches $2,830 Phase 2 begins |
All costs until you
have paid $4,550
out-of-pocket After that Phase 3 begins |
$0 deductible $2.50 Generic drugs $6.30 or 5% whichever is greater for Brand name and Specialty drugs |
*The benefit information provided herein is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage.
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