Providence Oregon Standard Silver Plan – Signature Network – EPO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	EPO
Deductible	$150 per person $150 per person
Out-of-pocket max	$1,075 per person $2,150 per family
Metal tier	Silver

Visit Copay

Primary care visit	$10 copay
Specialist visit	$20 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$30 copay
Emergency room	10% coinsurance after deductible
Ambulance	10% coinsurance after deductible
Hospital stay (facility)	10% coinsurance after deductible
Hospital stay (physician)	10% coinsurance after deductible
Outpatient procedure (facility)	10% coinsurance after deductible
Outpatient procedure (physician)	10% coinsurance after deductible
Physical rehabilitation	$10 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	10% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	$10 copay
Non-preferred Brand	25% coinsurance
Specialty	25% coinsurance

Lab Tests and Diagnostic Procedures

X-rays	10% coinsurance after deductible
Imaging (CT/PET/MRI)	10% coinsurance after deductible
Blood work	10% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$10 copay
Psychiatric hospital stay	10% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://providencehealthplan.com/-/media/providence/website/pdfs/indi-fam/2024/SBC/OR/2024_Providence_Oregon_Standard_Silver_Plan_Signature_Network_06.pdf
Drug and medication plan formulary	http://www.ProvidenceHealthPlan.com/2024FormularyN
Search doctor list	https://providencehealthplan.com/signaturephppd