A non-government entity
Providence Medicare Prime + Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Providence Medicare Prime + Rx (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Providence Medicare Prime + Rx (HMO) in 2025, please refer to our full plan details page.
Providence Medicare Prime + Rx (HMO) is a HMO plan offered by Providence St Joseph Health available for enrollment in 2025 to people living in Portland Metro. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Providence Medicare Prime + Rx (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Providence Medicare Prime + Rx (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Providence Medicare Prime + Rx (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $250.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $5000.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Providence Medicare Prime + Rx (HMO) plan has a $250 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy type. For generic drugs in the preferred pharmacy, the copay is $10, while it is $20 in a standard pharmacy. For preferred brand drugs, the copay is $100, regardless of the pharmacy. Non-preferred drugs have a 30% coinsurance. After your total drug costs reach $2000, you will enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Providence Medicare Prime + Rx (HMO) plan offers a range of benefits with varying cost-sharing. This plan includes coverage for inpatient and outpatient hospital services, with copays ranging from $40 to $450, depending on the service. The plan also covers services like ambulance, emergency, primary care, preventive, hearing, vision, dental, and home health services. Additional benefits include coverage for services such as hearing exams, vision exams, and dental services with copays between $35 and $40. Other benefits include coverage for diagnostic and radiological services, medical equipment, skilled nursing facility (SNF) services, and cardiac rehabilitation services, with varying copays and coinsurance. The plan also covers some "Other Services," including acupuncture and over-the-counter items, and it offers a meal benefit for chronic illnesses.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric with prior authorization. For Inpatient Hospital-Acute, you'll pay a $450 copay for days 1-4 and no copay for days 5-90, while additional days have no copay; Inpatient Hospital Psychiatric has a $320 copay for days 1-5 and no copay for days 6-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and additional days and non-Medicare covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a $450 copay, observation services with a $90 copay, ambulatory surgical center services with a $250 copay, and outpatient substance abuse services with a $40 copay per session. Outpatient blood services are also covered, including services not usually covered by Medicare plans, with a three-pint deductible waived.
Partial Hospitalization See details
Partial Hospitalization is covered by the Providence Medicare Prime + Rx (HMO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Providence Medicare Prime + Rx (HMO) plan. Ground and Air Ambulance Services have a copay of $50-$275, and there is no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Providence Medicare Prime + Rx (HMO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $25 copay, and Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $25 copay, and Worldwide Emergency Transportation has a $275 copay.
Primary Care See details
The Providence Medicare Prime + Rx (HMO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $35 copay, physician specialist services with a $35 copay, and mental health specialty services with a $35 copay for individual and group sessions. It also covers other health care professionals with a copay ranging from $0 to $35, psychiatric services, physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits with a copay between $0 and $40, and opioid treatment program services with a copay between $0 and $40. Podiatry services are not covered.
Preventive Services See details
The Providence Medicare Prime + Rx (HMO) plan covers preventive services, including Medicare-covered services with prior authorization and additional services like alternative therapies with a $20 copay. The plan does not cover health education, in-home safety assessments, post-discharge in-home medication reconciliation, re-admission prevention, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, or counseling services.
Hearing Services See details
Hearing services include coverage for hearing exams with a $40 copay, as well as fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a copay between $699 and $999 per year, but inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services include coverage for eye exams with a $40 copay, and eyewear with 20% coinsurance. Routine eye exams are covered once per year, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered. The plan has a combined maximum benefit of $250 per year for eyewear.
Dental Services See details
The Providence Medicare Prime + Rx (HMO) plan covers dental services, including oral exams with a $35 copay, dental x-rays, prophylaxis (cleaning) with a $35 copay, and fluoride treatment with a $35 copay. Other services such as Other Diagnostic Dental Services, Restorative Services, Adjunctive General Services, Endodontics, Prosthodontics, removable, Maxillofacial Prosthetics, Implant Services, Prosthodontics, fixed, Oral and Maxillofacial Surgery, and Orthodontics are offered as optional, supplemental benefits.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%. Other Medicare Part B Drugs and Medicare Part B Chemotherapy/Radiation Drugs are covered with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Providence Medicare Prime + Rx (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered by the Providence Medicare Prime + Rx (HMO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic devices have a 20% coinsurance, while medical supplies have a 20% coinsurance. Diabetic Equipment is covered, but Diabetic Supplies are not covered; Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with all diagnostic services requiring prior authorization and no copay for Medicare-covered lab services. Diagnostic Procedures/Tests and Diagnostic Radiological Services have a coinsurance of at most 20%, while Therapeutic Radiological Services have a coinsurance of at most 20%. Outpatient X-Ray Services have a $15 copay.
Home Health Services See details
Home Health Services are covered by the Providence Medicare Prime + Rx (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover the sub-services of Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services. There is a copay for the covered services, but the amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
The "Other Services" benefit covers acupuncture with a $20 copay per visit, up to 18 treatments per year. Over-the-counter items are also covered, with a maximum coverage amount of $110 every three months. The plan also offers a meal benefit for chronic illnesses, and some services are not covered, including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, Private Duty Nursing Services, and Case Management (Long Term Care).
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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