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Providence Health Plan is a health plan with a Medicare contract. - page 1 / 32





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Providence Health Plan is a health plan with a Medicare contract.

Introduction to the Summary of Benefits for Providence Medicare Extra + RX (HMO)

January 1, 2011 - December 31, 2011 Portland Metro, Willamette Valley and Clark County

Thank you for your interest in Providence Medicare Extra + RX. Our plan is offered by PROVIDENCE HEALTH PLAN, a Medicare Advantage Health Maintenance Organization (HMO). This Summary of Benefits tells you some features of our plan. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call Providence Medicare Extra + RX and ask for the "Evidence of Coverage".

YOU HAVE CHOICES IN YOUR HEALTH CARE As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like Providence Medicare Extra + RX. You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program.

You may join or leave a plan only at certain times. Please call Providence Medicare Extra + RX at the telephone number listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more information. TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week.

HOW CAN I COMPARE MY OPTIONS? You can compare Providence Medicare Extra + RX and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers.

Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year.

WHERE IS PROVIDENCE MEDICARE EXTRA + RX AVAILABLE? The service area for this plan includes: Clackamas, Columbia, Lane, Marion, Multnomah, Polk, Washington, Yamhill Counties, OR; Clark County, WA. You must live in one of these areas to join the plan.

WHO IS ELIGIBLE TO JOIN PROVIDENCE MEDICARE EXTRA + RX? You can join Providence Medicare Extra + RX if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End Stage Renal Disease are generally not eligible to enroll in Providence Medicare Extra + RX unless they are members of our organization and have been since their dialysis began.

CAN I CHOOSE MY DOCTORS? Providence Medicare Extra + RX has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory or for an up-to-date list visit us at www.providence.org/healthplans. Our customer service number is listed at the end of this introduction.


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