Providence Medicare Reverence (HMO-POS)
H9047 - 035 - 0
(3.5 / 5)
Providence Medicare Reverence (HMO-POS) is a Medicare Advantage (Part C) Plan by Providence Medicare Advantage Plans.
This page features plan details for 2024 Providence Medicare Reverence (HMO-POS) H9047 – 035 – 0 available in Portland, Will Valley, Clark, Central OR, SE WA.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Providence Medicare Reverence (HMO-POS) is offered in the following locations.
Plan Overview
Providence Medicare Reverence (HMO-POS) offers the following coverage and cost-sharing.
| Insurer: | Providence Medicare Advantage Plans |
| Health Plan Deductible: | $0.00 |
| MOOP: | $4,500.00 |
| Drugs Covered: | No |
Ready to sign up for Providence Medicare Reverence (HMO-POS) ?
Premium Breakdown
Providence Medicare Reverence (HMO-POS) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $174.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Providence Medicare Reverence (HMO-POS) also provides the following benefits.
| $0 |
| In-network | No |
| $10,000 In and Out-of-network $4,500 In-network $10,000 Out-of-network |
| Yes |
| In-network | No |
| In-network | $250 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | 30% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $15 copay per visit (Not applicable.) (Not applicable.) |
| out-of-network Primary | $25 copay per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $30 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $50 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $25 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $15 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $30 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $399-699 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fluoride treatment | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Occupational therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network | $50-250 copay (Not applicable.) (Not applicable.) |
| out-of-network | $50-250 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $30 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $35 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $300 per day for days 1 through 6 $0 per day for days 7 through 90 $0 per day for days 90 and beyond (Authorization is required.) (Referral is not required.) |
| out-of-network | 30% per stay (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $275 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | 30% per stay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $160 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | 30% per stay (Authorization is required.) (Referral is not required.) |
| Monthly Premium | $33.00 |
| Deductible | $150.00 |
| Monthly Premium | $45.00 |
| Deductible | $150.00 |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $32.50 |
| Preventive dental: | Deductible: | $150.00 |
| Comprehensive dental: | Monthly Premium: | $32.50 |
| Comprehensive dental: | Deductible: | $150.00 |
Package #2
| Preventive dental: | Monthly Premium: | $45.10 |
| Preventive dental: | Deductible: | $150.00 |
| Comprehensive dental: | Monthly Premium: | $45.10 |
| Comprehensive dental: | Deductible: | $150.00 |
Ready to sign up for Providence Medicare Reverence (HMO-POS) ?
Table of Contents
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