How To Get A Plan From Providence Mcare

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1 PROVIDENCE MEDICARE ADVANTAGE PLANS 2016 Plan Comparison Central Oregon and Hood River County H9047_2016PHP42 ACCEPTED

2 Service area map Columbia River Washington Oregon Clark Providence Medicare Compass + RX (HMO-POS) Providence Medicare Latitude + RX (HMO-POS) Additional in-network providers may be available 2

3 Providence Medicare Advantage Plans Part C Monthly premium includes prescription drug coverage Providence Medicare Compass + RX (HMO- POS) Providence Medicare Latitude + RX (HMO-POS) $118 $144 In -plan Out - of -plan In- plan Out -of-plan Deductible $0 $0 Benefits You pay You pay Out-of-pocket maximum $3,400 $6,700 combined $3,400 $5,500 combined Doctor office visit (PCP) $25 $45 $15 $30 Specialist visit $45 $40 $60 $60 no referral $50 no referral $50 Secure video visits $0 No coverage $0 No coverage Preventive care $0 30% $0 20% Lab 20% 30% 20% 20% X-ray 20% 30% 20% 20% Durable medical equipment 20% 30% 20% 20% Diabetic supplies $0 30% $0 20% Outpatient surgery $295 30% $200 20% Inpatient hospital Skilled nursing facility Days 1-7: $340 Days 8 & beyond: $0 Days 1-20: $0 Days : $150/ day 30% 30% Days 1-7: $250/day Days 8 & beyond: $0 Days 1-20: $0 Days : $100/ day Home health 20% 30% $0 20% Mental health and chemical dependency $40 30% $40 20% counseling Therapy: PT, OT, ST $40 30% $40 20% Medical eye exam $45 $75 $40 $50 Routine eye exam (through VSP providers) Vision hardware allowance (through VSP providers) $25 $25 copay Covered up to $45 $20 $100 every two years $100 every two years $100 every two years 20% 20% $20 copay Covered up to $45 $100 every two years Worldwide coverage Urgent care* $40 $40 $30 $30 Emergency room* $65 $65 $65 $65 Ambulance (air/ground) $300 one way $300 one way $150 one way $150 one way * Diagnostic testing copayment may apply. For office visits, other charges may apply. Copayment waived if admitted within 24 hours for the same condition. 3

4 Pharmacy coverage Part D How it works Deductible for Providence Medicare Initial coverage Coverage gap Catastrophic coverage Compass + RX Phase 1 Phase 2 Phase 3 (HMO-POS) When the total paid You pay only 45% of You pay whichever of $30 by you and the plan the costs of brand these is larger: either reaches $3,310, Phase 2 name drugs and 58% 5% coinsurance for begins. of the costs of generic the cost of the drug or drugs. You stay in this $2.95 copay for generic stage until your out- drugs, $7.40 copay for of-pocket costs reach brand name or specialty $4,850. After that Phase drugs. 3 begins. What you pay in Phase 1 Providence Medicare Compass Providence Medicare Latitude + RX (HMO -POS) + RX (HMO-POS) Drug tier Preferred network pharmacy Network pharmacy Drug tier Preferred network pharmacy Deductible $30 Deductible $0 Network pharmacy 1- Preferred generic $10 $12 1- Preferred generic $4 $10 2- Non-preferred generic $18 $20 2- Non-preferred generic $12 $20 3- Preferred brand $47 3- Preferred brand $45 4- Non-preferred brand $95 4- Non-preferred brand 5- Injectable meds 32% 5- Injectable meds 33% 6- Specialty meds 32% 6- Specialty meds 33% $95 4

5 2016 Optional Supplemental Dental Benefits For members of Providence Medicare Advantage Plans Monthly premium Basic Option $33.70 Enhanced Option $48.20 Plan Benefits Office visit copay Out -of - In -network network member member responsibility responsibility* No copay In -network member responsibility Out -of - network member responsibility* No copay Annual deductible 1 $50 $150 $50 $150 Annual maximum $1,000 $1,500 Waiting periods None None Provider network Any licensed dentist 2 Any licensed dentist 2 Out-of-network reimbursement Maximum allowable charge Maximum allowable charge Diagnostic & preventive services Oral examinations 3 0% 20% 0% 20% Semi-annual teeth cleaning 4 0% 20% 0% 20% Bitewing X-rays 5 0% 20% 0% 20% Full, panoramic and other diagnostic X-rays 6 0% 20% 0% 20% Comprehensive dental services Basic fillings & simple extractions 50% 60% 50% 60% Dentures 7 50% 60% 50% 60% Crowns and bridges 8, 9 50% 60% 50% 60% Oral surgery Not covered 50% 60% Endodontics (root canals) Not covered 50% 60% Periodontics Not covered 50% 60% Prosthodontics, other oral/ maxillofacial surgery Not covered 50% 60% *Important note: Out-of-network dentists may charge more than the amount allowed by Providence Medicare Advantage Plans. If this happens, they may "balance bill" you 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, scaling and polishing teeth) limited to two per calendar year 5 Bitewing X-rays limited to two per calendar year 6 Full, panoramic or other diagnostic X-rays limited to one per five years 5 7 $250 lifetime denture benefit 8 Crown/bridge max (Basic) - $100 per tooth per year 9 Crown/bridge max (Enhanced) - $500 per year

6 Why choose Providence? Medicare can be confusing but partner with Providence and we ll be with you every step of the way. Our commitment to your health and well-being means our comprehensive Medicare Advantage plans will cover you when you need it, but our multitude of other programs and services will also help you feel better and live well. That s the Providence difference. Variety of plans and options Our plans and options were designed 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. Expansive network With thousands of network providers you ll have convenient access to quality care when you need it. We care about you We care for others while striving for quality of life. That s why we donate vital health care services specific to the issues and challenges of the local communities we serve. Experience and innovation We re part of Providence Health & Services, one of the nation s top 10 most integrated health care providers 1 and serving the Pacific Northwest for nearly 160 years. This legacy along with innovative health care delivery options like telemedicine and close collaboration between our hospitals and clinics means you get the very best care possible. 6

7 Convenient ways to help you live healthily We want you to get the most for your money. That s why we offer additional services and resources to give you more value for your Providence Medicare Advantage Plan. With myprovidence you can access our one-stop secure member portal anytime, day or night. View your claims and benefit information, search for a provider or explore ways to improve your health and wellness with added tools and resources. No-cost gym membership through the Silver&Fit Exercise and Healthy Aging program 2 Health express, for convenient, no-appointment needed, online video visits with Providence providers. (See benefits table for cost information.) ProvRN, for 24/7 nurse advice for health related questions any time, day or night Health and wellness classes; enjoy a $500 annual benefit on a variety of wellness topics including smoking cessation and weight management at participating hospitals. To learn more: 1. Call us at or (TTY: 711). Service is available between 8 a.m. and 8 p.m. (Pacific time). Seven days a week, Oct. 1 - Feb. 14; Monday through Friday, Feb Sept Visit us online at 3. Attend a free community meeting 3 1 According to a list of the top 100 most highly integrated health systems published by IMS Health. 2 The Silver&Fit program is provided by American Specialty Health Fitness, Inc. (ASH Fitness). Silver&Fit, Silver&Fit Connected!, and the Silver&Fit logo are federally registered trademarks of American Specialty Health Incorporated, the parent company of ASH Fitness, and used with permission herein. 3 A sales person will be present with information and applications. For accommodation of persons with special needs at sales meetings, call or (TTY: 711). Providence Health Plan is an HMO and HMO-POS plan with a Medicare contract. Enrollment in Providence Health Plan depends on contract renewal. Medicare has neither reviewed, nor endorsed this information. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/ or co-payments/co-insurance may change on January 1 of each year. The formulary, pharmacy network, and provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B premium. 7

8 OUR MISSION As people of Providence, we reveal God s love for all, especially the poor and vulnerable, through our compassionate service. OUR CORE VALUES Respect, Compassion, Justice, Excellence, Stewardship Providence Medicare Advantage Plans Sales Team P.O. Box 5548 Portland, OR or ; TTY: 711 Service is available between 8 a.m. and 8 p.m. (Pacific time), seven days a week (Oct. 1 - Feb. 14) Monday through Friday (Feb Sept. 30) Providence Health & Services, a not -for-profit health system, is an equal -opportunity organization in the provision of health care services and employment opportunities Providence Health Plan. All rights reserved. Printed on paper that contains 10% post-consumer waste. MDC-254C_HP A_HP_C-OR_HR