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Providence Health Assurance

Providence Medicare Advantage Plans 2019 Plan Year Changes

Medicare - Align Group Plan + Rx (HMO)

• The Prescription Drug out-of-pocket maximum per person per

calendar year is $5,100 Medicare – Flex Group Plan + Rx (HMO-POS)

• The Prescription Drug out-of-pocket maximum per person per

calendar year is $5,100 Non-Medicare

• The Core Value and Select Value plans are no longer available

Providence Health Assurance

Medicare Advantage Plans

Medical

• Lower cost shares, examples:

‒ Hospital, outpatient surgery, ambulance and ER

• Lower out-of-pocket maximum
• Benefit stability

Pharmacy

• No Part D deductible
• No coverage gap/donut hole
• No catastrophic coverage phase; the PHIP Rx plan has a true out-of-

pocket maximum

• A not to exceed per prescription cape of $250 for a month supply

The Value of the Providence Medicare Advantage Plans and PHIP Partnership

Providence Medicare Advantage Plans Enrollment Service Area

Oregon – Benton, Clackamas, Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Linn, Marion, Multnomah, Polk, Washington, Wheeler and Yamhill Washington – Clark County

Providence Medicare Advantage Plan Options

Features

Type of Plan Monthly Premium Out-of-Pocket Costs Provider Access Primary Care Physician Referral Requirement

Align Group

HMO Higher Premium Low In-Plan Only Required Referral Required Both plans provide the same:

• Covered services
• Network of contracted providers
• Part D prescription drug program

Differences between the plans, outside of the monthly premium:

• Amounts paid at time of service and
• verall out-of-pocket cost
• How you access a service (in or out-of-

network with or without a referral)

Flex Group

HMO-POS Lower Premium Moderate In-Plan or Out-of-Plan Required Referral Optional

Providence Medicare Advantage Plan Options

Benefit Coverage Align (HMO) Plan Flex (HMO-POS) Plan Member Responsibility In-Network Out-of-Network Deductible None None None Out-of-Pocket Maximum $1,500 per individual $3,000 per individual Primary Care Office Visit $15 copay $20 copay $30 copay Specialist Office Visit $20 copay $25 copay $35 copay Inpatient Hospitalization $100 copay per day $500 maximum per admit $125 copay per day $500 max per admit 20% Outpatient Surgery $75 copay $150 copay 20% Lab Tests $0 $0 20% X-ray 10% 10% 20% Pharmacy 40% of charge up to $250 maximum per 31-day supply Pharmacy Out-of-Pocket Maximum $5,100 per individual

Providence Medicare Advantage Plans

Emergency and Travel Benefits

Service Align Group Flex Group

Urgent Care* (Worldwide coverage) $25 copay $25 copay Emergency Room* (Worldwide coverage) $50 copay $65 copay

Ambulance* (Worldwide, air or ground) $50 copay $50 copay Travel Benefit (Nationwide, must use a Medicare Provider)

Follow-up Care $1,000 allowance Providence pays 80% Member pays 20% $30 copay for a doctor visit $35 copay for a specialist visit 20% for all other services

*No coverage limit on Emergency, Urgent Care or Ambulance

Providence Medicare Advantage Plans

Extra Benefits

• Care Management Assistance
• No lifetime reserve days limit on

hospitalization

• Streamlined skilled nursing facility

admission

• $500 annual benefit for health and

wellness classes

• Annual Routine vision exam covered

‒ Align plan $15 copay ‒ Flex plan $20 copay

• $100 frame allowance once every 2

years

• No-cost fitness center membership

‒ For a list of contracted facilities visit www.silverandfit.com

5 Star plan

• Our Medicare plans for 2018 received Medicare’s highest possible

rating, 5 out of 5 stars

Providence Medicare Advantage Plans Special Attributes

• Over 11,000 in-network providers and growing
• Providers closed to Medicare; may be open to see

you with a Providence Medicare Advantage Plan

• No balance billing

Quality of service

• Local customer service; based in Beaverton Oregon
• Dedicated service team for prospective members
• Free Nurse Advice Line – available 24 hours a day 7 days a week
• Nurse Care Managers who personally assist with complex medical needs

Online resources

• Physician finder
• Rx formulary
• Benefit specific detail
• Value added services and discounts
• myProvidence
• Mobile ID App
• Visit www.providencehealthassurance.com/phip

Providence Medicare Advantage Plans Special Attributes

Alternative ways to receive care

Providence Medicare Advantage Plans Extra Benefits

Providence Express Care Clinics

• Less expensive than urgent care - Same cost as a PCP visit
• Available from 8am to 8pm or 7am to 7pm seven days a week
• To locate an Express Clinic, visit:

https://www.providence.org/our-services/expresscare/locations

Providence Express Care Virtual

• $0 Cost Share on all Plans
• Video visit with a Providence care

provider on a smartphone, tablet or computer

• No appointment necessary
• Available 8am to Midnight, 7 days a

week

• virtual.providence.org

Providence Health Assurance

Part D Prescription Drug Plan

Pharmacy Network Benefit

Examples of Preferred Network Pharmacies* Walgreens Target Fred Meyer Wal-Mart Safeway Rite Aid Costco Bi-Mart

*Not all contracted network pharmacies are listed. Pharmacies contracted with your health plan may change at any time. Your health plan will notify you if your pharmacy is no longer included in the network. Please contact your health plan for more details.

Providence PHIP Formulary

• Covers a broad list of medications

– Formulary available online at www.ProvidenceHealthAssurance.com/PHIP Included Medication Therapy Management (MTM)

• MTM services are associated with improved medication use, lower drug costs,

improved disease management, reduced hospitalizations and reduced hospital readmissions

• Free service for our Medicare members

Pharmacies

• Over 34,000 participating pharmacies to choose from

throughout the nation

• Two types of contracted pharmacies:

‒ work Pharmacies ‒ Preferred Network & Mail Order Pharmacies ▫ Deeper discounts, to help save you money ▫ Over 90% of our pharmacies are preferred