A non-government entity
Providence Medicare Pine + Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Providence Medicare Pine + 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 Pine + Rx (HMO) in 2026, please refer to our full plan details page.
Providence Medicare Pine + Rx (HMO) is a HMO plan offered by Providence St Joseph Health available for enrollment in 2025 to people living in SE WA, Spokane and Snohomish counties. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Providence Medicare Pine + 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 Pine + 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 Pine + 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. Additionally, this plan comes with a Part B Premium reduction of $24.00. You must continue to pay paying your reduced 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 $195.00 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 Pine + Rx (HMO) plan features an annual drug deductible of $195. Under this plan, you will pay no copay for Tier 1 preferred generic drugs filled at a preferred pharmacy or through standard mail order, while standard pharmacies charge a $16 copay for a one-month supply. Tier 2 generic drugs also feature no copay through standard mail order, but cost a $10 copay at preferred pharmacies and a $20 copay at standard pharmacies for a one-month supply. For Tier 3 preferred brand drugs, you will pay a $47 copay for a one-month supply at retail pharmacies, or a lower $40 copay through standard mail order. Tier 4 non-preferred drugs carry a $100 copay for a one-month supply across all pharmacy options, including mail order. Finally, Tier 5 specialty drugs require a 30% coinsurance for a one-month supply at both retail and standard mail-order pharmacies.
Additional Benefits
The Providence Medicare Pine + Rx (HMO) plan offers robust coverage for essential healthcare needs with predictable cost-sharing and no deductibles for many services. Members benefit from no copay for primary care visits, while specialist consultations, routine hearing exams, and annual eye exams require a $45 copay with no coinsurance. Inpatient hospital stays require a daily copay for the first few days and no copay thereafter, while emergency room visits carry a $130 copay that is waived if you are admitted. For specialized care and recovery, preventive and most comprehensive dental services are covered with no copay, and home health services also feature no copay or coinsurance. Skilled nursing facility stays have no copay for the first 20 days, whereas durable medical equipment and dialysis services require a 20% coinsurance with no copay. This plan successfully minimizes out-of-pocket expenses by eliminating coinsurance for the majority of doctor visits, outpatient services, and hospital stays.
Inpatient Hospital See details
Providence Medicare Pine + Rx (HMO) covers inpatient hospital services with no coinsurance, requiring prior authorization for both acute and psychiatric stays. Acute stays require a $395 daily copay for days 1 through 4 and no copay for days 5 and beyond, while psychiatric stays require a $325 daily copay for days 1 through 5 and no copay for days 6 through 90. Non-Medicare-covered stays, acute upgrades, and psychiatric additional days are not covered.
Outpatient Services See details
Providence Medicare Pine + Rx (HMO) covers outpatient hospital services with a $310 copay, observation services with a $90 copay per stay, and ambulatory surgical center services with a $250 copay, all with no coinsurance. Outpatient substance abuse services require a $45 copay per individual or group session with no coinsurance, and outpatient blood services are covered with no copay or coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by Providence Medicare Pine + Rx (HMO) with a $55 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Providence Medicare Pine + Rx (HMO) covers ground and air ambulance services with a copay of $50.00 to $275.00 and no coinsurance, though prior authorization is required. Some transportation services are covered under the plan, but transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Providence Medicare Pine + Rx (HMO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services have a $25 copay and no coinsurance, and worldwide emergency services are covered with no coinsurance and copays ranging from $25 to $275.
Primary Care See details
Providence Medicare Pine + Rx (HMO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $45 copay and no coinsurance. Physical, occupational, mental health, and psychiatric therapies require a $40 copay and no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive Services are partially covered by Providence Medicare Pine + Rx (HMO) with no copay and no coinsurance for covered options like annual physicals and kidney disease education. However, several sub-services are not covered, including health education, in-home safety assessments, post-discharge medication reconciliation, readmission prevention, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home/bathroom safety modifications, and counseling services.
Hearing Services See details
Providence Medicare Pine + Rx (HMO) covers hearing exams with a $45 copay, no coinsurance, and no deductible, which includes one routine exam per year and unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $499 to $999 for up to two devices per year, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Providence Medicare Pine + Rx (HMO), excluding other eye exam services while covering one routine eye exam annually with a $45 copay and no coinsurance. Eyewear is covered with no copay, no coinsurance, and no deductible, up to a $100 annual maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
Dental services are covered under the Providence Medicare Pine + Rx (HMO) plan, with Medicare-covered dental requiring a $45 copay and no coinsurance, while preventive and most comprehensive services are offered with no copay and no coinsurance. This benefit is partially covered, as implant services, orthodontics, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
Providence Medicare Pine + Rx (HMO) covers Home Infusion bundled Services with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and insulin, carry a coinsurance of up to 20% (with a minimum of no coinsurance), with insulin also requiring a $35 copay.
Dialysis Services See details
Dialysis services are covered under the Providence Medicare Pine + Rx (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Providence Medicare Pine + Rx (HMO) covers durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance, requiring prior authorization. Diabetic equipment is partially covered, offering therapeutic shoes and inserts with no copay and 20% coinsurance, but diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by Providence Medicare Pine + Rx (HMO), with lab services and outpatient X-ray services excluded from coverage. Covered diagnostic procedures and radiological services require prior authorization and feature no copay and a 20% coinsurance.
Home Health Services See details
Home health services are covered under the Providence Medicare Pine + Rx (HMO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Providence Medicare Pine + Rx (HMO) does not cover Cardiac Rehabilitation Services, meaning no plan copays or coinsurance apply to cardiac, intensive cardiac, pulmonary, or SET for PAD rehabilitation services.
Skilled Nursing Facility (SNF) See details
Providence Medicare Pine + Rx (HMO) covers skilled nursing facility (SNF) services with no coinsurance and no prior three-day hospital stay requirement, 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, with no coverage for additional days beyond the Medicare limit.
Other Services See details
Other Services are not covered under the Providence Medicare Pine + Rx (HMO) plan, which excludes coverage for acupuncture, over-the-counter (OTC) items, and meal benefits.
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