Connect 1500 Gold

Plan Details

Connect 1500 Gold

Plan Overview
Plan Benefits
Additional Features

Overview

Annual Deductible	$1,500/$3,000
Out-of-Pocket Maximum	$8,200/$16,400

Connect Network

Formulary N

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Important note about these benefits

Below you will find the amount you will pay for in-network services after you have met your calendar year deductible.

When you see a (), the deductible does not apply.

Benefit Summary

On-Demand Visits

Providence ExpressCare Virtual visits	Covered in full
Providence ExpressCare Retail Health Clinic visits	Covered in full

Preventive Care

Periodic health exams and well-baby care	Covered in full
Routine immunizations and shots	Covered in full
Colonoscopy (preventive, age 45+)	Covered in full
Gynecological exams (1 per calendar year), breast exams and Pap tests	Covered in full
Mammograms	Covered in full
Nutritional Counseling	Covered in full
Tobacco cessation, counseling/classes and deterrent medications	Covered in full

Physician/Professional Services

Office visits to a Primary Care Provider In-Person Virtually	$30 $10
Office visits to an Alternative Care Provider (In-Person or Virtually) (such as naturopath) (Chiropractic manipulation and acupuncture services are covered separately from the office visit at the levels listed for those benefits.)	$30
Office visits to specialists (In-Person or Virtually)	$50
Inpatient Hospital visits	20%
Allergy shots and allergy serums, injectable and infused medications	20%
Surgery and anesthesia in an office or facility	20%

Diagnostic Services

X-ray, lab and testing Services (includes ultrasound)	20%
High-tech imaging Services (such as PET, CT or MRI)	20%
Sleep studies	20%

Emergency Care and Urgent Care Services

Emergency Services
(For Emergency Medical Conditions only. If admitted to the Hospital, all Services subject to inpatient benefits.)
In-Network
Out-of-Network

$250 then 20%

Emergency medical transportation (air and/or ground)
(Emergency transportation is covered regardless of whether or not the provider is an In-Network Provider.)
In-Network
Out-of-Network

20%

Urgent Care visits (for non-life threatening illness/minor injury)
In-Network
Out-of-Network

$50

Hospital Services

Inpatient/Observation care	20%
Skilled Nursing Facility (limited to 60 days per calendar year)	20%
Inpatient rehabilitative care (Limited to 30 days per calendar year; 60 days for head/spinal injuries. Limits do not apply to Mental Health Services.)	20%
Inpatient habilitative care (Limited to 30 days per calendar year; 60 days for head/spinal injuries. Limits do not apply to Mental Health Services.)	20%

Outpatient Services

Outpatient surgery at an Ambulatory Surgery Center	10%
Outpatient surgery at a Hospital-based facility	20%
Colonoscopy (non-preventive) at an Ambulatory Surgery Center	10%
Colonoscopy (non-preventive) at a Hospital-based facility	20%
Outpatient dialysis, infusion, chemotherapy and radiation therapy	20%
Cardiac Rehabilitation (post-surgery)	First 16 visits Covered in full then 20% after deductible
Outpatient rehabilitative services: physical, occupational or speech therapy (Limited to 30 visits per calendar year; up to 30 additional visits per specified condition. Limits do not apply to Mental Health Services.)	20%
Outpatient habilitative services: physical, occupational or speech therapy (Limited to 30 visits per calendar year; up to 30 additional visits per specified condition. Limits do not apply to Mental Health Services.)	20%
Vision Therapy (convergence insufficiency) (Limited to 12 visits per lifetime)	20%

Maternity Services

Prenatal visits	Covered in full
Delivery and postnatal physician/provider visits	10%
Inpatient Hospital/facility services	20%
Routine newborn nursery care	20%

Medical Equipment, Supplies and Devices

Medical equipment, appliances, prosthetics/orthotics and supplies	20%
Diabetes supplies (such as lancets, test strips, needles, and glucose monitors)	20%
Hearing aids (Limited to one aid per ear every 3 calendar years)	20%
Removable custom shoe orthotics (Limited to $200 per calendar year)	20%

Mental Health and Substance Use Disorder

Inpatient and residential services	20%
Day treatment, intensive outpatient, and partial hospitalization services	20%
Outpatient provider visits In-Person Virtually	$30 $10
Applied Behavior Analysis	20%

Home Health and Hospice

Home health care	20%
Hospice care	Covered in full
Respite care (limited to Members receiving Hospice care; limited to 5 consecutive days, up to 30 days per lifetime)	20%

Biofeedback

Biofeedback for specified diagnosis (limited to 10 visits per lifetime)

20%

Chiropractic Manipulation and Acupuncture

Chiropractic manipulations (limited to 20 visits per calendar year)	$25
Acupuncture (limited to 12 visits per calendar year)	$25

Prescription Drugs

Up to a 30-Day Supply

Up to a 30-day supply from a participating retail, preferred or specialty pharmacy
Tier 1	Covered in full
Tier 2	$10
Tier 3	$50
Tier 4	50%
Tier 5	50% with $200 per script cap
Tier 6	50%

90-Day Supply: Preferred Retail

90-day supply from a participating preferred retail pharmacy
Tier 1	Covered in full
Tier 2	$30
Tier 3	$150
Tier 4	50%

90-Day Supply: Mail Order

90-day supply from a participating mail order pharmacy
Tier 1	Covered in full
Tier 2	$20
Tier 3	$100
Tier 4	45%

Routine Vision Services

Pediatric Vision Services (under age 19)

Routine eye exam (limited to 1 exam per calendar year)	Covered in full
Lenses (limited to 1 pair per calendar year) Single vision Lined bifocal Lined trifocal Lenticular lenses	Covered in full
Frames (limited to 1 pair per calendar year; select from VSP’s Otis & Piper ™ Eyewear Collection)	Covered in full
Contact lens services and materials in place of glasses Standard: 1 pair per calendar year (1 contact lens per eye) Monthly: 6 month supply per calendar year (6 lenses per eye) Bi-weekly: 3 month supply per calendar year (6 lenses per eye) Dailies: 3 month supply per calendar year (90 lenses per eye)	Covered in full

Adult Vision Services

Routine eye exam (limited to 1 exam per calendar year)

$25

Pediatric Dental Service (under age 19)

Preventive

Routine Exams 2 per every 12 months	Covered in full
Bitewing X-rays 4 per every 6 months	Covered in full
Cleanings 1 per every 6 months	Covered in full
Topical Fluoride 1 per every 6 months	Covered in full
Fissure sealants 1 service per tooth (molar) per every 60 months	Covered in full
Space Maintainers	Covered in full

Basic

Restorative fillings

50%

Major

Oral surgery (extractions and other minor surgical procedures)	50%
Endodontics and Periodontics	50%
Stainless Steel Crowns/Anterior Primary or Posterior Primary/Permanent 1 service per tooth every 7 years	50%
Porcelain Crowns 1 service per tooth every 7 years for children ages 16 and older (limited to tooth numbers 6-11, 22 and 27 only)	50%
Denture and bridge work (construction or repair of fixed bridges, partials and complete dentures) Limited to 1 every 10 years for complete dentures and 1 every 10 years for partials for Members ages 16 and older	50%

Benefit Summary PDF

We want you to get the most for your money. Whether your goals include better health and fitness or you just need a little extra assistance, our health plans include great perks and care options to make achieving your True Health that much easier.

Member Perks

Health Coaching

We can help you work towards a healthier you.

It's time to team up. Whether you'd like to increase your activity level, reduce stress, improve your eating habits, lose weight, quit tobacco or just feel better every day, a Providence health coach can help. We’re here to remove barriers, support your efforts, motivate you when you need a nudge and be a resource on your journey to a healthier, happier you.
Learn more
Behavioral Health Resources

We're here for you when you need us.

Meet with a licensed mental health provider that best suits your needs, fully confidential – always.
Learn more
ChooseHealthy®

Save big while you achieve your health goals.

We want to give you every opportunity we can to help you achieve your True Health. Save big on wellness products and memberships that will help you thrive on your road to better health.
Learn more
Active&Fit Direct™

Big discounts on your fitness membership.

Whether you’re ready to kick-start your routine — or just looking to level up — the Active&Fit Direct™ program allows you to choose from more than 16,000 participating fitness centers and YMCAs nationwide for $25 a month (plus a $25 enrollment fee and applicable taxes; 2-month commitment required).
Learn more
ID Protection

Enjoy the peace of mind you deserve.

We’ve partnered with Assist America Identity Theft Protection® to give you 24/7 access to identity theft protection experts, fraud monitoring and warning notifications, resolution services, and lost or stolen card assistance.
Learn more
Travel Assistance

Accidents happen. We've got you covered.

We’ve partnered with Assist America Travel Assistance® to provide you with the logistical support for your emergency medical needs when you’re traveling internationally or at least 100 miles or more from your home.
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LifeBalance

Health and well-being go hand in hand.

That’s why we’ve partnered with LifeBalance to give you and your family access to discounts on more than 20,000 recreational, cultural, and travel related businesses and activities.
Learn more

Member Care Options

ProvRN – Free

Access to care 24/7.

Health issues don’t fit neatly into a 9 to 5 schedule — and neither should your access to health information. Providence Health Plan members can call ProvRN around the clock to ask questions about their health.
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ExpressCare Clinics – Free*

Same day in-person treatment.

When you need to see someone and your regular care provider is not available. With many convenient locations, it’s easy to find a clinic near you.
Learn more

*Washington health plans may have a copay when utilizing ExpressCare Clinics. Washington health plans have a copay when utilizing ExpressCare Clinics.
ExpressCare Virtual – Miễn phí*

Nhận được dịch vụ chăm sóc mà quý vị muốn, vào lúc mà quý vị cần.

Trao đổi với nhà cung cấp từ bất cứ đâu bằng máy tính bảng, điện thoại thông minh hoặc máy tính. Đây là lựa chọn tuyệt vời cho các đơn thuốc và phương pháp điều trị không yêu cầu chăm sóc trực tiếp. Được cung cấp trên toàn quốc.
Tìm hiểu thêm

Thăm khám qua ExpressCare Virtual miễn phí cho hầu hết các chương trình bảo hiểm y tế của Providence. Các thành viên HSA trước tiên phải đạt đến mức khấu trừ của chương trình, nhưng chi phí thăm khám ExpressCare thấp hơn đáng kể so với thăm khám tại phòng khám. Các dịch vụ phụ trợ, chẳng hạn như xét nghiệm sinh hóa, có thể phải chịu chia sẻ chi phí bổ sung.
Primary Care – $

Your primary healthcare partner.

Primary care providers develop a relationship with you and know your health history. Visit them for check-ups, managing chronic conditions, and specialist referrals.
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Urgent Care – $$

When you need help right away.

Urgent care is where you turn when you know you need help and can’t wait for an appointment. This is best for minor injuries, cuts, burns, pains, and sprains.
Learn more
Emergency Care – $$$

When you think you may be in danger.

Use emergency care for symptoms like suspected heart attack, stroke, severe abdominal pain, poisoning, choking, loss of consciousness, and uncontrolled bleeding.
Learn more

If you ever think your life or well-being could be in serious danger, call 911 immediately.

Individual & Family Resources