A non-government entity
Providence Medicare Extra + Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Providence Medicare Extra + 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 Extra + Rx (HMO) in 2025, please refer to our full plan details page.
Providence Medicare Extra + Rx (HMO) is a HMO plan offered by Providence St Joseph Health available for enrollment in 2025 to people living in Portland, Will Valley, Central OR, Clark, WA. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Providence Medicare Extra + 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 Extra + 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 Extra + Rx (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $161.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4000.00 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 Extra + Rx (HMO) plan has an enhanced alternative drug benefit with no deductible. In the initial coverage phase, you'll pay a copay for your prescriptions depending on the drug tier and pharmacy. For example, preferred generic drugs have a $10 copay at preferred pharmacies and a $0 copay at standard mail order pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. If you qualify for the low-income subsidy, your Part D premium will be $14.40. Be sure to check the plan's formulary for specific drug coverage details.
Additional Benefits
The Providence Medicare Extra + Rx (HMO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have copays ranging from $0 to $250, depending on the type of care and length of stay. Outpatient services, primary care, and vision services have copays, while preventive services include coverage for exams and additional benefits. This plan also covers ambulance, emergency, and hearing services, with copays applying to some services. Dental and home infusion services are available, along with coverage for dialysis, medical equipment, and diagnostic services. The plan offers additional benefits such as transportation, hearing aids, and over-the-counter items, but some services like long-term care and specific therapies are not covered.
Inpatient Hospital See details
The Providence Medicare Extra + Rx (HMO) plan covers inpatient hospital stays, including acute and psychiatric care, with prior authorization required. For Inpatient Hospital-Acute, you pay a $250 copay for days 1-5, and no copay for days 6-90, with additional days 91-999 having no copay; non-Medicare covered stays and upgrades are not covered. For Inpatient Hospital-Psychiatric, you pay a $200 copay for days 1-7, and no copay for days 8-90, while additional days and non-Medicare covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $150 copay, Observation Services with a $70 copay, Ambulatory Surgical Center (ASC) Services with a $100 copay, and Outpatient Substance Abuse Services with a $20 copay for both individual and group sessions. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by this plan and requires prior authorization. There is no information about the cost of this benefit.
Ambulance and Transportation Services See details
Ambulance services are covered with a copay of $50-$275 for both ground and air ambulance services. Transportation services to plan-approved health-related locations are covered for up to 24 one-way trips per year, with various modes of transportation available. 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. Emergency Services has a $125 copay, Urgently Needed Services has 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 Extra + Rx (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services, physician specialist services, and physical therapy and speech-language pathology services have a $20 copay. Occupational therapy services, individual and group mental health and psychiatric sessions, and opioid treatment program services have a $0-$20 copay. Other health care professional services have a $0-$20 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Providence Medicare Extra + Rx (HMO) plan covers preventive services, including Medicare-covered preventive services, annual physical exams, and additional preventive services. Some additional services are not covered, including health education, in-home safety assessments, post-discharge in-home medication reconciliation, re-admission prevention, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, and counseling services. Personal Emergency Response Systems (PERS), Medical Nutrition Therapy (MNT), wigs for hair loss related to chemotherapy, additional sessions of smoking and tobacco cessation counseling, fitness benefit, remote access technologies, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit are also covered.
Hearing Services See details
Hearing Services includes coverage for hearing exams with a $20 copay, fitting and evaluation for hearing aids, and prescription hearing aids. Prescription hearing aids have a copay between $699 and $999, and the plan does not cover prescription hearing aids for the inner ear, outer ear, or over the ear.
Vision Services See details
Vision services include eye exams with a $20 copay, eyewear with a combined maximum benefit of $250 per year, and contact lenses, eyeglasses, eyeglass lenses, eyeglass frames, and upgrades are also covered. Routine eye exams are limited to one per year.
Dental Services See details
The Providence Medicare Extra + Rx (HMO) plan covers Medicare Dental Services with a $20 copay, Oral Exams, Dental X-Rays, Prophylaxis (Cleaning), and Fluoride Treatment. Other Diagnostic Dental Services, Other Preventive Dental Services, Restorative Services, Adjunctive General Services, Endodontics, Prosthodontics, removable, Prosthodontics, fixed, and Oral and Maxillofacial Surgery are offered as an optional, supplemental benefit. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay, and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Providence Medicare Extra + Rx (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and no copay, Prosthetics/Medical Supplies with a 20% coinsurance and no copay, and Diabetic Equipment. Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Providence Medicare Extra + Rx (HMO) plan. Diagnostic Procedures/Tests have a coinsurance of at most 20%, while Lab Services are not covered. Diagnostic Radiological Services and Therapeutic Radiological Services each have a coinsurance of at most 15%, but Outpatient X-Ray Services are not covered.
Home Health Services See details
Home Health Services are covered by the Providence Medicare Extra + Rx (HMO) plan with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. There is a copay for some services, but the specific cost is not listed in the provided information.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Providence Medicare Extra + Rx (HMO) plan, but require prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include Over-the-Counter (OTC) Items with a maximum benefit of $160 every three months, and a Meal Benefit for a chronic illness. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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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.
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