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 2026, 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 2026.
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 $6750.00 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 features a $250 annual drug deductible. For Tier 1 preferred generic drugs, you will pay no copay at preferred pharmacies or through standard mail order. Tier 2 generic drugs also offer no copay through standard mail order, or a low $10 copay for a one-month supply at preferred pharmacies. For brand-name and specialty medications, costs vary depending on the drug tier. Tier 3 preferred brand drugs require a $47 copay for a one-month supply at retail pharmacies, which drops to $40 through standard mail order. Tier 4 non-preferred drugs carry a $100 monthly copay, while Tier 5 specialty drugs require a 30% coinsurance regardless of the pharmacy type you choose.
Additional Benefits
The Providence Medicare Prime + Rx (HMO) plan offers comprehensive coverage for essential medical needs, featuring no copay for primary care visits and covered preventive services. Specialist visits require a $35 copay, while inpatient hospital stays have a $450 daily copay for the first four days and no copay for subsequent days. Emergency room visits carry a $130 copay, and outpatient hospital services require a $450 copay, with no coinsurance for either service. For supplemental care, the plan provides preventive dental services with no copay and annual routine eye exams for a $40 copay. Skilled nursing facility stays require no copay for the first 20 days, while durable medical equipment and dialysis services are covered with a 20% coinsurance and no copay.
Inpatient Hospital See details
Providence Medicare Prime + Rx (HMO) covers inpatient acute hospital stays with no coinsurance and a copay of $450 per day for days 1 to 4, followed by no copay for unlimited additional days. Inpatient psychiatric care is covered with no coinsurance and a copay of $320 per day for days 1 to 5, then no copay for days 6 to 90. Prior authorization is required, and non-Medicare-covered stays, upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Providence Medicare Prime + Rx (HMO) covers outpatient services with no coinsurance, featuring a $450 copay for outpatient hospital services, a $90 copay per stay for observation services, and a $250 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $40 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by Providence Medicare Prime + Rx (HMO) with a $55.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Providence Medicare Prime + Rx (HMO) covers ground and air ambulance services with a $50.00 to $275.00 copay and no coinsurance, though prior authorization is required. For transportation benefits, some services are covered, but transportation to plan-approved health-related locations and any health-related locations are not covered.
Emergency Services See details
Providence Medicare Prime + Rx (HMO) covers emergency services with a $130 copay and urgently needed services with a $25 copay, both with no coinsurance and waived if admitted to the hospital within 24 hours. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays of $130, $25, and $275, respectively.
Primary Care See details
Providence Medicare Prime + Rx (HMO) provides primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, and mental health services carry a $35 copay and no coinsurance. Additional telehealth and opioid treatment services range from a $0 to $40 copay with no coinsurance, though podiatry and chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by Providence Medicare Prime + Rx (HMO) with no copay and no coinsurance for covered benefits like annual physical exams, kidney disease education, and diabetes self-management. While services like medical nutrition therapy and smoking cessation counseling are covered, several other options such as fitness benefits, weight management programs, health education, and alternative therapies are not covered.
Hearing Services See details
Hearing services are partially covered by Providence Medicare Prime + Rx (HMO), excluding OTC hearing aids as well as inner ear, outer ear, and over the ear prescription hearing aids. Covered hearing exams require a $40 copay and no coinsurance, while covered prescription hearing aids have a copay ranging from $499 to $999 with no coinsurance.
Vision Services See details
Providence Medicare Prime + Rx (HMO) covers routine eye exams once per year with a $40 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and a 20% coinsurance for contact lenses, up to a $100 combined annual maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
Providence Medicare Prime + Rx (HMO) features partially covered dental services, providing Medicare-covered dental care with a $35 copay and no coinsurance, alongside preventive and diagnostic services with no copay and no coinsurance. While many restorative and periodontic treatments are included, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Providence Medicare Prime + Rx (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs have no copay and a coinsurance ranging from no coinsurance to 20%, while Part B insulin is covered with a $35 copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered under the Providence Medicare Prime + Rx (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is partially covered by Providence Medicare Prime + Rx (HMO) with no copay and a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes or inserts. Prior authorization is required for these services, and diabetic supplies are not covered under this plan.
Diagnostic and Radiological Services See details
Diagnostic and radiological services under Providence Medicare Prime + Rx (HMO) are partially covered and require prior authorization, though lab services are not covered. Covered diagnostic procedures and therapeutic radiology require a 20% coinsurance and no copay, while diagnostic radiology requires a 20% coinsurance and a copay, and outpatient X-rays require a $15 copay and coinsurance.
Home Health Services See details
Home health services are covered by Providence Medicare Prime + Rx (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered under Providence Medicare Prime + Rx (HMO) with no coinsurance; however, some services are covered while standard cardiac rehabilitation (with a $10 copay), intensive cardiac rehabilitation (with a $40 copay), pulmonary rehabilitation (with a $15 copay), and supervised exercise therapy for peripheral artery disease (with a $25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Providence Medicare Prime + Rx (HMO) with no coinsurance and do not require a prior three-day hospital stay, though prior authorization is required. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, while additional days beyond the 100-day limit are not covered.
Other Services See details
Other services are not covered by Providence Medicare Prime + Rx (HMO), including acupuncture, over-the-counter (OTC) items, and meal benefits.
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