A non-government entity
Providence Medicare Sycamore + Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Providence Medicare Sycamore + 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 Sycamore + Rx (HMO) in 2025, please refer to our full plan details page.
Providence Medicare Sycamore + Rx (HMO) is a HMO plan offered by Providence St Joseph Health available for enrollment in 2025 to people living in Orange County. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Providence Medicare Sycamore + 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 Sycamore + 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 Sycamore + 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $400.00 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 Sycamore + Rx (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying copays or coinsurance amounts depending on the drug tier and pharmacy you use. For example, preferred generic drugs have no copay if you use standard mail, but have a $20 copay at a standard pharmacy. 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 (LIS), you will also pay $0 for your prescriptions. Always check the plan's formulary for specific drug coverage details.
Additional Benefits
The Providence Medicare Sycamore + Rx (HMO) plan offers a wide range of benefits with varying costs. Many services have no copay, including inpatient hospital stays, home health, urgently needed services, and diagnostic services. The plan also covers outpatient services, ambulance and transportation, emergency services, primary care, preventive services, hearing, vision, dental, and home infusion services. Additional benefits include coverage for dialysis, medical equipment, diagnostic and radiological services, skilled nursing facilities, and other services like acupuncture, over-the-counter items, and a meal benefit. There are copays for some services, such as ambulance, emergency services, and hearing aids, and coinsurance for medical equipment. However, some services, like cardiac rehabilitation services, are not covered, so be sure to read the details.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. Inpatient Hospital-Acute has no copay for Medicare-covered stays and Additional Days for Inpatient Hospital-Acute also has no copay. Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, and ambulatory surgical center (ASC) services, are covered and require prior authorization. Outpatient substance abuse services, including individual and group sessions, are covered with a copay between $10.00 and $10.00. Outpatient blood services are also covered, with a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered by the Providence Medicare Sycamore + Rx (HMO) plan. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
The Providence Medicare Sycamore + Rx (HMO) plan covers ambulance services with a $100 copay for both ground and air ambulance services, and transportation services to plan-approved health-related locations with 60 one-way trips per year using various modes of transport. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services, are covered by the Providence Medicare Sycamore + Rx (HMO) plan. Emergency Services have a $125 copay and no coinsurance, while Worldwide Emergency Coverage has a $125 copay, and Worldwide Emergency Transportation has a $100 copay, with no coinsurance for either. Urgently Needed Services has no copay and no coinsurance.
Primary Care See details
The Providence Medicare Sycamore + Rx (HMO) plan covers primary care physician services, chiropractic services (with a doctor referral), occupational therapy services, physician specialist services (with a doctor referral), other health care professional services (with a doctor referral), physical therapy and speech-language pathology services, additional telehealth benefits (with prior authorization and a doctor referral), and opioid treatment program services (with prior authorization). Individual and group sessions for mental health and psychiatric services are not covered, and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with prior authorization, annual physical exams, additional preventive services, kidney disease education services, and other preventive services. Some services such as Health Education, In-Home Safety Assessment, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Weight Management Programs, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing Services include routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams are limited to 1 per year, and fitting/evaluation for hearing aids is unlimited. Prescription hearing aids (all types) are covered with a copay between $399 and $699 for 2 hearing aids per year, while prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision services include coverage for routine eye exams, eyewear, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Routine eye exams are covered once per year, and eyewear has a combined maximum benefit of $250 per year.
Dental Services See details
Dental services are covered, with a maximum plan benefit of $2,700 per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are all covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Providence Medicare Sycamore + Rx (HMO) plan. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%, and for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Providence Medicare Sycamore + Rx (HMO) plan. You will pay a copay between $25.00 and $25.00 for this benefit.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and no copay, Prosthetics/Medical Supplies, 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, though some services are not. All Diagnostic services are covered with no copay, but Diagnostic Procedures/Tests and Lab Services are not covered. Therapeutic Radiological Services are covered with a copay of at most $50.00, but Diagnostic Radiological Services and Outpatient X-Ray Services are not covered.
Home Health Services See details
Home Health Services are covered by the Providence Medicare Sycamore + Rx (HMO) plan with no copay or coinsurance, although authorization is required. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Providence Medicare Sycamore + Rx (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $50. Additional days beyond Medicare-covered SNF and non-Medicare-covered SNF stays are not covered.
Other Services See details
The "Other Services" benefit includes acupuncture, over-the-counter (OTC) items, and a meal benefit. Acupuncture is covered with a limit of 24 treatments per year. OTC items are covered up to $190 every three months, and the unused amount carries forward to the next period, and also includes nicotine replacement therapy and Naloxone coverage. The meal benefit is for a chronic illness. However, 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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