SUMMARY OF BENEFITS
If you have any questions about this plan’s benefits or costs, please contact Providence Health Plan.
Providence Medicare Extra + RX
29 - Prescription Drugs (continued)
You will not be reimbursed for the difference between the Out-of- Network Pharmacy charge and the plan's In-Network allowable amount.
Out-of-Network Catastrophic Coverage
After your yearly out-of-pocket drug costs reach $ 4,550, you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share, which is the greater of:
A $2.50 copay for generic (including brand drugs treated as generic) and a $6.30 copay for all other drugs, or 5% coinsurance.
You will not be reimbursed for the difference between the Out-of- Network Pharmacy charge and the plan's In-Network allowable amount
30 - Dental Services
Preventive dental services (such as cleaning) not covered.
General Authorization rules may apply.
In general, preventive dental benefits (such as cleaning) not covered.
$15 copay for Medicare-covered dental benefits.
Separate Office Visit cost sharing of $15 may apply.