2019 Plan Overview - Providence Health Plan/media/Files...This guide gives you an overview of Providence Health Plan’s 2019 large group products, all designed to meet the unique

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2019 Plan OverviewG R O U P S S I Z E D 51+

2 ProvidenceHealthPlan.com

WELCOME TO PROVIDENCE HEALTH PLAN, YOUR TRUSTED PARTNER FOR EMPLOYEE HEALTH NEEDS.

Providence St. Joseph Health has been serving the community for more than

160 years. Through our ministries, we have a singular commitment to improve

the health of all, especially the poor and vulnerable. The communities we

serve rely on our compassionate care and our steadfast commitment

to helping all people find their True Health. Our goal is simple: to

transform health care. Providence is taking steps to make health care

more convenient, more accessible and more affordable for everyone.

This guide gives you an overview of Providence Health Plan’s 2019

large group products, all designed to meet the unique needs of area

businesses. Our 2019 product portfolio includes a number of plans,

some with broad networks, others with tailored networks. Each plan

offers a range of cost share options and many plans include benefits

that are covered in full.

We’d be honored to partner with you and help meet your business

goals this year.

ProvidenceHealthPlan.com 3

Table of Contents

Why Choose Providence? 4

New for 2019 6

What Members Get with Providence 8

What Employers Get with Providence 9

Our Provider Networks 10

Option Advantage Plans 12

Option Advantage A Plans 14

Option Advantage B Plans 16

Option Advantage AB Plans 18

HSA Qualified Plans 20

HSA and HSA E Qualified Plans 22

Integrated HSA, HRA or FSA 24

Connect Plans 26

Choice Plans 28

Pharmacy Plans 30

Chiropractic Manipulation and Acupuncture Plans 31

Vision Plans 32

Providence Dental Plans 33

Important Contact Information 35


Why Choose Providence?

2014 2015 2016 2017100,000

200,000

300,000

400,000

500,000

600,000

700,000

MEMBERSHIP640,397

MEMBERSHIP638,759

MEMBERSHIP547,070

MEMBERSHIP469,568

We’ve grown steadily the past several years, allowing us to serve more than 600,000 members throughout Oregon and southwest Washington. Our growth demonstrates that we are doing the right thing—offering the right products—for customers, and offering compassionate, quality care for members.

GROWING RESPONSIBLY

Have confidence that you are partnering with a company that’s financially strong and stable. The state of Oregon

requires insurance carriers to have strong financial reserves so they are positioned to honor commitments to groups and members. Providence Health Plan is proud to exceed the state’s reserve requirement by three times, allowing us to steadfastly serve our members and the greater community.

• A full suite of health plans for a complete health benefit program: medical, pharmacy, dental, vision, chiropractic and acupuncture plus many free extras to encourage members to get and stay engaged with their health—and have some fun while they’re doing it!

• A range of quality products and choice of plan designs with broad or tailored provider networks help you better manage health benefit program costs.

Financially Strong High-Performing Quality Products

A TRUSTED

PARTNER

SERVING THE

COMMUNITY

FOR MORE THAN

32 YEARS


We know that excellent, accurate and compassionate service means a better experience for you and your employees.

Medicare Advantage Plans 5-star rating

5 STARS IN 2018 - THE HIGHEST RATING POSSIBLE

We are one of only 23 plans nationally that achieved 5-star status including D-SNP MA populations after two years retaining a 4.5 star rating.

Superior Service—True to Our Mission

The Right Care to Manage Rising CostsREADMISSION AVOIDANCE

In 2016, we averaged a 7 percent readmission rate— 85 percent better than the national readmission rate.

Best of all—our approach to the right care means that employees

are present and healthy at work and our community is healthier.

OPTIMIZING CARE GUIDELINES:

We’re optimizing site-of-care guidelines to help curb escalating prescription drug costs. We’re also providing assistance to members to help them adhere to taking medications as prescribed.

BEST-IN-CLASS GENERIC DRUG UTILIZATION:

Our 91 percent generic fill rate helps manage rising costs of prescription medications. For every one percent increase in generic fill rates, plan costs can be reduced up to 2.5 percent.

98.7%

97.5%

99.7%

of total clean claims are processed within 30 days

of overall claims are processed accurately—the first time

of financial claims are accurate

Historic CMS star rating

2015

2018

20165

5

2017 4.5

4.5

91%

New for 2019


• Introducing ID protection through Assist America. Members who enroll through our partner, Assist America, will be protected from fraud if a credit card is lost or stolen.

• New travel assistance support through Assist America. Members who need emergency medical transportation services can call Assist America when they’re 100 miles or more away from home or in another country. Travel assistance is included for personal, vacation and business travel.

• First-dollar coverage. Members enrolled in our HSA plans will no longer need to meet their deductible for diabetic supplies.

• Additional HSA plans. A new suite of HSA options includes an embedded deductible/out-of-pocket maximum option.

• Aligned HSA cost shares. Specialist cost shares are aligned with primary care cost shares on HSA plans.

• Changes to the Option Advantage plan. Most medical services on our base Option Advantage plan will be covered after the deductible. This affordable plan option includes preventive care covered in full. Combine this with one of our pharmacy plans and optional supplemental riders, which are not subject to the deductible. This plan is perfect when paired with a health reimbursement account (HRA) available through our preferred partner, HealthEquity®.

• New Deductible. A $4,000 deductible option will be added to all Option Advantage plans.

• Out-of-pocket maximum indexed. Plans that currently offer the highest allowed out-of-pocket maximum will be indexed to $7,900, the new Affordable Care Act (ACA) maximum allowed in 2019. HSA plans with the highest allowed maximum will be indexed up to $6,750, the new IRS maximum allowed.

Take a look at what’s new for our 2019 large group product portfolio. We’ve added some new extra values:


GREAT MEMBER PERKS

• Express Care Retail, Express Care Virtual and Web-direct visits are all covered in full, where available. For members enrolled on an HSA plan, the deductible applies, but the cost is significantly less than a visit to the doctor’s office

• Free health advice—24/7—with ProvRN, our nurse advice line

• Free health coaching encourages and motivates members

• Award-winning case and disease management with nurse care coordinators supporting members living with chronic conditions

• Exclusive LifeBalance discounts on cultural and recreational activities members enjoy

• myProvidence online health tools (i.e., Wellness Central and Treatment Cost Calculator) that are easy to find and use


What members get with ProvidenceMembers get extra value for their health care dollars. Our extra values and discounts can help them stay active and healthy.

Express Care Virtual Members can visit a health care provider at their convenience via their computer, smartphone or tablet. Services are covered in full on most Providence health plans, meaning they can access care when they want it at no cost. If they’re enrolled in an HSA plan the deductible applies, but an Express Care Virtual visit is significantly less expensive than an office visit.

Health Coaching Whether they’d like to lose weight, increase their physical activity or just feel better, when members call us they will join the 93 percent of Providence health coaching participants who’ve made a lifestyle improvement.

ProvRN Members can call anytime—24/7—to get free medical advice from a Providence registered nurse.

LifeBalance Members can participate in fun activities and get discounts on things they love to do, from seeing a movie to getting away for less with unique vacation packages.

Travel Assistance With a single phone call to Assist America, members get access to a unique global emergency assistance program. It immediately connects them to doctors, hospitals, pharmacies and other services if they experience a medical or non-medical emergency while traveling.

Active&Fit DirectTM Instead of paying expensive health club membership fees, Providence members can join the Active&Fit program for $25 a month. They can choose from more than 9,000 participating fitness centers nationally.

ChooseHealthy® With ChooseHealthy, members get discounts on acupuncture, chiropractic care, massage therapy and dietitian services—for a well-rounded approach to self-care.

ID Protection With Assist America’s Identify Theft Protection, eligible members who enroll are protected from the often devastating consequences of identity theft. This program provides tools to help prevent theft of personal data, and restore its integrity if used fraudulently.


What employers get with ProvidenceEmployers have access to a deep bench of resources, designed to create a healthy and fit workforce.

Choice of Plans – A variety of plan types with a range of cost share options to meet business needs. Coverage options include medical, pharmacy, chiropractic manipulation and acupuncture, vision and dental services.

Employee Assistance – An optional employee assistance program is designed to help employees resolve issues affecting work and family through comprehensive counseling and referrals to community resources.

Account Integration – An option with Providence, simplified integration of health savings accounts, health reimbursement accounts and flexible spending accounts through our partner, HealthEquity.

FitTogether – An answer to population health management, FitTogether empowers employees to find their fit. Whether partnering with a health coach to managing chronic conditions or engaging in classes and programs to make positive lifestyle changes, our suite of services includes a dedicated health management consultant and secure online health tools. Encourage enrolled employees to sign up for FitTogether, a newsletter dedicated to members’ health.

A.B.C.


Great care, robust benefits and the right network can help keep employees healthy and help employers manage costs. Take a look at our networks:

Our Provider Networks

The Providence Signature NetworkA robust network with nearly 1 million providers nationwide.

The Providence Choice NetworkA tailored provider network offering access to nearly 300 medical home clinics located in Oregon and southwest Washington. Clinics in this network have been recognized by the Oregon Health Authority for providing patient-focused, coordinated and affordable care.

The Providence Connect NetworkA tailored Portland-area provider network offering access to more than 70 medical home clinics located in Washington, Multnomah, Clackamas and Hood River counties in Oregon, and the city of Newberg in Yamhill County. Clinics in this network have been recognized by the Oregon Health Authority for providing patient-focused, coordinated and affordable care.

• Clackamas County• Hood River County• Multnomah County• Washington County• The city of Newberg in Yamhill County

• Baker• Benton• Clackamas• Clark (WA)• Coos• Crook• Curry • Deschutes

• Douglas• Hood River • Josephine• Klamath• Lane• Lincoln• Linn• Malheur

• Marion• Multnomah• Polk• Umatilla• Union• Wallowa• Washington• Yamhill


*Members must call our partner, Assist America, to enroll in this program.

Free services (Services covered in full when care is received in-network)

Option Advantage

Option Advantage

A

Option Advantage

B

Option Advantage

ABHSA HSA E Choice Connect

On-demand primary provider visits · · · · · ·ACA preventive care · · · · · · · ·ProvRN medical advice · · · · · · · ·Telephonic health coaching · · · · · · · ·LifeBalance discount program · · · · · · · ·Disease management for chronic conditions · · · · · · · ·Health coaching (12 sessions/year) · · · · · · · ·ID Protection* · · · · · · · ·Travel Assistance · · · · · · · ·Provider Network

Broad PPO-style network, the Providence Signature Network · · · · · ·Team-based medical home care · ·Referral needed for select specialty care · ·Plan Design

Optional combined in- and out-of-network deductibles and out-of-pocket maximums

· · · · · ·Plan Benefits

Preventive care covered in full · · · · · · · ·Most services covered after the deductible is met · · ·Deductible waived for in-network PCP and specialist visits

· · · · ·Deductible waived for in-network urgent care visits · · · · ·Specialist copay is the same as PCP copay · ·Higher cost shares for select services, such as knee and shoulder arthroscopy and knee and hip replacement

· ·

Integrated Account Administration

Option to pair with an integrated HSA,HRA and FSA administered by HealthEquity

· · · · · · · ·

The right product can help manage costs and keep employees healthy.


PLAN FEATURES:

• Lowest premiums of all Option Advantage plans• Deductible waived on preventive services• Express Care Virtual, Express Care Clinic and Web-direct visits, where available;

deductible waived and covered in full• Split Primary Care Physician (PCP) and specialist copay• Option for a common or separate deductible

UNIQUE PLAN INFORMATION:

• Excellent base plan for employers who offer two or more plan options • Most benefits are subject to the deductible• Pairs nicely with an HRA (optional, and can be integrated with our partner, HealthEquity)• Flexibility to choose among any of our pharmacy benefit plans; pharmacy benefits

are not embedded and not subject to the deductible

PLAN DESIGN OPTIONS:

In-Network PCP/Specialist Office Visit Copay

In-/Out-of-Network In-Network,

Out-of-Pocket Maximum In-Network Deductible

$15/$25 10%/20% $2,000 $250

$20/$30 20%/40% $2,500 $500

$25/$35 30%/50% $3,000 $750

$35/$45 $3,500 $1,000

$4,000 $1,500

$5,000 $2,000

$6,350 $2,500

$7,900 $3,000

$4,000

$5,000

Option Advantage Plans Revamped for 2019 – bringing more savings to employers!

Members get affordable coverage and access

to our lowest premium compared to all Option

Advantage choices. An ideal plan for employers

who want to offer a low-cost medical plan

paired with one of our pharmacy benefit plans.

THE PROVIDENCE SIGNATURE NETWORK

A nationwide network of nearly 1 MILLION providers.


PLAN FEATURES:

• Lowest premiums of all Option Advantage plans• Deductible waived on preventive services• Express Care Virtual, Express Care Clinic and Web-direct visits, where available;

deductible waived and covered in full• Split Primary Care Physician (PCP) and specialist copay• Option for a common or separate deductible

Option Advantage Plans: Benefit Highlights

üNo deductible needs to be met prior to receiving this benefit$ Copay applies and % coinsurance appliesCIF Covered in full

In-network Out-of-network

On-Demand Provider Visits What the member pays

Express Care Virtual or Web-direct visits CIF ü Not coveredVirtual visits to a specialist by phone and video or Web-direct visit $5 to $30 Not covered

Preventive Care Services

Periodic health exams and well-baby care CIF ü 20% to 50% üRoutine immunizations and shots CIF ü 20% to 50%Colonoscopy (age 50+) CIF ü 20% to 50% Gynecologic exams, pap tests CIF ü 20% to 50% üMammograms CIF ü 20% to 50%Tobacco cessation, counseling/classes and deterrent medications CIF ü Not covered

Physician/Provider Services

Office visits to a PCP $15 to $35/visit 20% to 50% Office visits to alternative care providers $15 to $35/visit 20% to 50% Office visits to specialists/other providers $25 to $45/visit 20% to 50% Allergy shots and serums 10% to 30% 20% to 50%Infusions and injectable medications 10% to 30% 20% to 50%Surgery, anesthesia in an office or facility 10% to 30% 20% to 50%

Diagnostic Services

Lab and X-ray service 10% to 30% 20% to 50%Imaging services, PET, CT, MRI 10% to 30% 20% to 50%

Emergency and Urgent Care Services

Emergency services (for emergency medical conditions only; if admitted to the hospital all services are subject to inpatient benefits)

$250 $250

Urgent care services (for non-life-threatening illness/minor injury) $25 to $45/visit 20% to 50% Emergency medical transportation (air and/or ground) 10% to 30% 10% to 30%

Hospital Services

Inpatient/observation care 10% to 30% 20% to 50%Rehabilitative care (limited to 30 days per calendar year) 10% to 30% 20% to 50%Habilitative care (limited to 30 days per calendar year) 10% to 30% 20% to 50%Skilled nursing facility (limited to 60 days per calendar year) 10% to 30% 20% to 50%

Outpatient Services

Outpatient infusion, dialysis, chemotherapy, radiation 10% to 30% 20% to 50%Temporomandibular joint (TMJ) services 50% Not coveredOutpatient rehabilitative physical therapy 10% to 30% 20% to 50%Outpatient rehabilitative occupational or speech therapy 10% to 30% 20% to 50%Outpatient habilitative physical, occupational or speech therapy 10% to 30% 20% to 50%

Maternity Services

Prenatal office visits CIF ü 20% to 50%Delivery and postnatal services, inpatient hospital/facility services, routine newborn nursery care

10% to 30% 20% to 50%


Offer members robust coverage with the

deductible waived on select services. These

plans offer significant choice of in-network

providers along with thousands of out-of-

network providers.

PLAN FEATURES:

• Deductible waived on in-network PCP, specialists, urgent care visits, allergy shots and outpatient physical therapy

• The first $500 of in-network lab and X-ray services is covered in full; deductible waived• Express Care Virtual, Express Care Clinic and Web-direct visits, where available;

deductible waived and covered in full• Split PCP and specialist copay• Option for a common or separate deductible


• Comprehensive plan with robust coverage• Plan design that’s easy to understand • Predictable costs


In-Network PCP/Specialist Copays

In-/Out-of-Network Coinsurance

In-Network OOP Max In-Network Deductible

$15/$25 10%/20% $2,000 $250

$20/$30 20%/40% $2,500 $500

$25/$35 30%/50% $3,000 $750

$35/$45 $3,500 $1,000

$4,000 $1,500

$5,000 $2,000

$6,350 $2,500

$7,900 $3,000

$4,000

$5,000

Option Advantage A Plans


A nationwide network of nearly

1 MILLION providers.


PLAN FEATURES:

• Deductible waived on in-network PCP, specialists, urgent care visits, allergy shots and outpatient physical therapy

• The first $500 of in-network lab and X-ray services is covered in full; deductible waived• Express Care Virtual, Express Care Clinic and Web-direct visits, where available;

deductible waived and covered in full• Split PCP and specialist copay• Option for a common or separate deductible

Option Advantage A Plans: Benefit Highlights




Express Care Virtual or Web-direct visits CIF ü Not coveredVirtual visits to a specialist by phone and video or Web-direct visit $5 to $30ü Not covered


Periodic health exams and well-baby care CIF ü 20% to 50% üRoutine immunizations and shots CIF ü 20% to 50%Colonoscopy (age 50+) CIF ü 20% to 50% Gynecologic exams, pap tests CIF ü 20% to 50% üMammograms CIF ü 20% to 50%Tobacco cessation, counseling/classes and deterrent medications CIF ü Not covered


Office visits to a PCP $15 to $35/visit ü 20% to 50% üOffice visits to alternative care providers $15 to $35/visit ü 20% to 50% üOffice visits to specialists/other providers $25 to $45/visit ü 20% to 50% üAllergy shots and serums 10% to 30% ü 20% to 50%Infusions and injectable medications 10% to 30% 20% to 50%Surgery, anesthesia in an office or facility 10% to 30% 20% to 50%

Diagnostic Services

Lab and X-ray services up to $500 CIF ü 20% to 50%Lab and X-ray after $500 10% to 30% 20% to 50%Imaging services, PET, CT, MRI 10% to 30% 20% to 50%



$250 $250

Urgent care services (for non-life-threatening illness/minor injury) $25 to $45/visit ü 20% to 50% Emergency medical transportation (air and/or ground) 10% to 30% 10% to 30%

Hospital Services


Outpatient Services

Outpatient infusion, dialysis, chemotherapy, radiation 10% to 30% 20% to 50%Temporomandibular joint (TMJ) services 50% Not coveredOutpatient rehabilitative physical therapy 10% to 30%ü 20% to 50%Outpatient rehabilitative occupational or speech therapy 10% to 30% 20% to 50%Outpatient habilitative physical, occupational or speech therapy 10% to 30% 20% to 50%

Maternity Services


10% to 30% 20% to 50%


Easy-to-use plans offering a choice of providers

and a deductible waived on many services. These

are excellent companion buy-up plans with access

to the Signature Network.

PLAN FEATURES:

• Deductible waived on many services, such as PCP, specialists, ER, lab and X-ray, imaging services (PET, CT, MRI), urgent care, allergy shots, routine immunizations, outpatient physical therapy

• Deductible waived on in-network delivery, postnatal and routine newborn nursery care; delivery is 10x PCP copay

• Express Care Virtual, Express Care Clinic and Web-direct visits, where available; deductible waived and covered in full

• Specialist’s office visit copay equals a PCP office visit copay• Available with common or separate deductible


• Comprehensive plan with robust coverage • Plan design that’s easy to understand • Predictable costs




In-Network OOP MaxIn-Network Deductible

$15/$15 10%/20% $2,000 $250

$20/$20 20%/40% $2,500 $500

$25/$25 30%/50% $3,000 $750

$35/$35 $3,500 $1,000

$4,000 $1,500

$5,000 $2,000

$6,350 $2,500

$7,900 $3,000

$4,000

$5,000

Option Advantage B Plans





PLAN FEATURES:

• Deductible waived on many services, such as PCP, specialists, ER, lab and X-ray, imaging services (PET, CT, MRI), urgent care, allergy shots, routine immunizations, outpatient physical therapy

• Deductible waived on in-network delivery, postnatal and routine newborn nursery care; delivery is 10x PCP copay

• Express Care Virtual, Express Care Clinic and Web-direct visits, where available; deductible waived and covered in full







Periodic health exams and well-baby care CIF ü 20% to 50% üRoutine immunizations and shots CIF ü 20% to 50% üColonoscopy (age 50+) CIF ü 20% to 50% Gynecologic exams, pap tests CIF ü 20% to 50% üMammograms CIF ü 20% to 50%Tobacco cessation, counseling/classes and deterrent medications CIF ü Not covered



Diagnostic Services

Lab and X-ray 10% to 30% ü 20% to 50%Imaging services, PET, CT, MRI 10% to 30% ü 20% to 50%



$250 ü $250 ü

Urgent care services (for non-life-threatening illness/minor injury) $15 to $35/visit ü 20% to 50% üEmergency medical transportation (air and/or ground) 10% to 30% 10% to 30%

Hospital Services


Outpatient Services


Maternity Services

Prenatal office visits CIF ü 20% to 50%Delivery and postnatal services 10x PCP visit ü 20% to 50%Routine newborn nursery care 10% to 30%ü 20% to 50%

Option Advantage B Plans: Benefit Highlights


These premier plans offer the richest

benefits of all Option Advantage plans.

Like all Option Advantage plans, they

offer significant provider choice with

in- and out-of-network providers.

PLAN FEATURES:

• Deductible waived on many in-network services such as PCP, specialists, ER, lab and X-ray, imaging services (PET, CT, MRI), urgent care, allergy shots, routine immunizations, outpatient physical therapy, the first $500 of in-network lab and X-ray services, in-network delivery, postnatal and routine newborn nursery care; delivery is 10 x PCP copay

• Express Care Virtual, Express Care Clinic and Web-direct visits, where available; deductible waived and covered in full.



• The premier Option Advantage plan• Comprehensive coverage and rich benefits• Plan design that’s easy to understand • Predictable costs




In-Network OOP MaxIn-Network Deductible

$15/$15 10%/20% $2,000 $250

$20/$20 20%/40% $2,500 $500

$25/$25 30%/50% $3,000 $750

$35/$35 $3,500 $1,000

$4,000 $1,500

$5,000 $2,000

$6,350 $2,500

$7,900 $3,000

$4,000

$5,000

Option Advantage AB Plans





Option Advantage AB Plans: Benefit Highlights






Periodic health exams and well-baby care CIF ü 20% to 50% üRoutine immunizations and shots CIF ü 20% to 50% üColonoscopy (age 50+) CIF ü 20% to 50% Gynecologic exams, pap tests CIF ü 20% to 50% üMammograms CIF ü 20% to 50%Tobacco cessation, counseling/classes and deterrent medications CIF ü Not covered



Diagnostic Services

Lab and X-ray services up to $500 CIF ü 20% to 50%Lab and X-ray after $500 10% to 30% 20% to 50%Imaging services, PET, CT, MRI 10% to 30% ü 20% to 50%



$250 ü $250 ü

Urgent care services (for non-life-threatening illness/minor injury) $15 to $35/visit ü 20% to 50% üEmergency medical transportation (air and/or ground) 10% to 30% 10% to 30%

Hospital Services


Outpatient Services


Maternity Services

Prenatal office visits CIF ü 20% to 50%Delivery and postnatal services 10x PCP visit ü 20% to 50%Routine newborn nursery care 10% to 30%ü 20% to 50%


PLAN FEATURES:

• Affordable premiums with most services subject to the deductible• In-network preventive care services are covered before the deductible• Express Care Virtual, Express Care Clinic and Web-direct visits, where available,

covered in full after deductible• Flexible plan designs, including embedded or aggregate deductible options, and

separate and common deductible and out-of-pocket maximums• A seamless member experience for tracking and paying HSA-qualified plan expenses

through integrated claims processing, available with HealthEquity. Visit Sales.HealthEquity.com/providence.

• Member tools to help manage health care costs

MEANINGFUL CHANGES FOR 2019:

• New! A new suite of HSA plan options.

• New! In-network diabetes supplies, such as lancets, test strips and needles, are covered before the deductible.

• New! The IRS indexed the out-of-pocket maximum to $6,750, the highest allowable for 2019.

• Reminder: Select preventive medications are not subject to the deductible. They are granted Safe Harbor, permitted by federal regulations, and are shown with the symbol SH in the online formulary.

New HSA Embedded Product

In addition to our current aggregate deductible HSA plans, Providence will begin offering additional plans with embedded deductibles and out-of-pocket

maximums in 2019. Here’s how these plans compare:

Embedded deductible: Each covered family member only needs to satisfy his/her individual deductible prior to receiving benefits.

Aggregate deductible: When two or more members are enrolled, the entire family deductible must be met before the plan begins to pay benefits for any individual family member.

High-deductible health plans offering premium

savings and allowing consumers to manage health

care costs. When combined with a qualified health

savings account (HSA), there are also tax advantages

to save for future health care expenses.

HSA Qualified Plans





New HSA Embedded Product

In addition to our current aggregate deductible HSA plans, Providence will begin offering additional plans with embedded deductibles and out-of-pocket

maximums in 2019. Here’s how these plans compare:

Embedded deductible: Each covered family member only needs to satisfy his/her individual deductible prior to receiving benefits.

Aggregate deductible: When two or more members are enrolled, the entire family deductible must be met before the plan begins to pay benefits for any individual family member.

PROVIDENCE HSA E (Embedded deductible and out-of-pocket maximum)

In-/Out-of-network Coinsurance

In-network Out-of-pocket maximum

Deductible

0%/0%* $3,000 $3,000

20%/40% $4,000 $3,500

50%/50% $5,500 $4,000

$6,750 $5,500

$6,750

PROVIDENCE HSA (Aggregate deductible and out-of-pocket maximum)

In-/Out-of-network Coinsurance

In-network Out-of-pocket maximum

Deductible

0%/0%* $3,000 $1,500

20%/40% $4,000 $2,000

50%/50% $5,500 $2,500

$6,750 $3,000

$3,500

$4,000

$5,500

$6,750

*Available when deductible and out-of-pocket maximums equal the same value.

HSA Qualified Plans: Plan Design Options


HSA and HSA E Qualified Plans: Benefit Highlights




Virtual visits to a PCP by phone and video (Express Care Virtual) or by Web-direct visits

CIF Not covered

Providence Express Care Retail Clinic CIF N/AVirtual visits to a specialist by phone and video 5% to 35% Not covered


Periodic health exams and well-baby care CIF ü 0% to 50%Routine immunizations and shots CIF ü 0% to 50%Colonoscopy (age 50+) CIF ü 0% to 50%Gynecologic exams, pap tests CIF ü 0% to 50%Mammograms CIF ü 0% to 50%Tobacco cessation, counseling/classes and deterrent medications CIF ü Not covered


Office visits to a PCP 0% to 50% 0% to 50%Office visits to alternative care providers (does not include chiropractic manipulation or acupuncture services)

0% to 50% 0% to 50%

Office visits to specialists/other providers 0% to 50% 0% to 50%Allergy shots and serums 0% to 50% 0% to 50%Infusions and injectable medications 0% to 50% 0% to 50%Surgery, anesthesia in an office or facility 0% to 50% 0% to 50%

Inpatient hospital visits 0% to 50% 0% to 50%

Prescription Drugs (up to a 30-day supply/retail and preferred retail pharmacies; 90-day supply/mail order and preferred retail pharmacies; Safe Harbor drugs are exempt from the deductible subject to the formulary and applicable cost share)

ACA preventive drugs CIF ü

Not covered

Preferred generic drugs 0% to 50%Non-preferred generic drugs 0% to 50%Preferred brand-name drugs 0% to 50%Specialty drugs (limited to a 30-day supply and must be obtained through a contracted specialty pharmacy)

0% or 50%

Compounded drugs (limited to a 30-day supply and must be obtained through a retail/preferred retail pharmacy)

0% or 50%

Diagnostic Services

Lab and X-ray services 0% to 50% 0% to 50%

High-tech imaging services (such as PET, CT, MRI) 0% to 50% 0% to 50%






0% to 50% 0% to 50%

Urgent care services (for non-life-threatening illness/minor injury) 0% to 50% 0% to 50% Emergency medical transportation (air and/or ground) 0% to 50% 0% to 50%

Hospital Services


Outpatient Services

Outpatient infusion, dialysis, chemotherapy, radiation therapy 0% to 50% 0% to 50%Temporomandibular joint (TMJ) services 0% or 50% Not covered Outpatient rehabilitative occupational and speech therapy 0% to 50% 0% to 50%Outpatient habilitative services 0% to 50% 0% to 50%

Maternity Services


0% to 50% 0% to 50%

HSA and HSA E Qualified Plans: Benefit Highlights (Continued)


Integrated HSA, HRA or FSA

Account TypeEmployee Account

Activation and Setup CostMonthly Administration Cost

Employer Plan Setup and Annual Plan Maintenance Fee

Health Savings Account (HSA)

Free$2.70

per accountFree

Health Reimbursement Arrangement (HRA)

Free$3.45

per account$250-$500

Flexible Spending Account (FSA)

Free$3.45

per account$250-$500

Limited purpose Flexible Spending Account

Free$1.95

per accountFree

An integrated Health Savings Account (HSA), Health Reimbursement Arrangement (HRA) or Flexible Spending Account (FSA) can lower out-of-pocket costs for employees and encourage them to be more engaged in their health and more judicious with their health care dollars. Both employers and employees can benefit from tax advantages associated with these accounts.

Providence partners with HealthEquity to provide seamlessly integrated HSA, HRA and FSA paired with our health plans at a competitive price. Through our partnership with HealthEquity, the nation’s oldest and largest dedicated health savings trustee, Providence makes integrating HSA, HRA or FSA easy with:

• Live 24/7 customer service• Online access to account information anytime–from paying providers to viewing claims • Integrated plan setup, enrollment, claims administration and billing so that health plan and

member accounts are set up in one convenient place• A fully-equipped employer portal that lets employers easily manage contributions, view

reporting and upload contribution information• Free HealthEquity mobile app gives members on-the-go access to account balances and claims

history plus the ability to send payments and reimbursements, initiate and document claims, and manage debit card transactions


being true to the people you serve

TRUE HEALTH IS


PLAN FEATURES:

• Affordable monthly premiums• Express Care Virtual, Express Care Clinic and Web-direct visits, where available;

deductible waived and covered in full • Integrated and coordinated care delivered by a network of Providence physicians• Referrals coordinated by a dedicated medical home team


• Ideal for cost-conscious employers looking to offer comprehensive and affordable health insurance to employees

• Members work closely with a dedicated medical home care team developing a personal care experience that takes the hassle out of health care

• Substantial premium savings• A Portland-area network with more than 70 primary care clinics recognized as

medical homes by the Oregon Health Authority for providing patient-focused, coordinated and affordable care





$15/$30 20%/40% $2,000 $500

$25/$50 30%/50% $2,500 $1,000

$35/$70 $3,000 $2,000

$3,500 $3,000

$4,000 $4,000

$6,350

$7,900

Connect Plans

Connect plans combine a medical home model of care with a tailored provider network to achieve substantial premium savings. Members select a medical home from our Portland metro area Providence Connect Network. The medical home model provides a team of health professionals dedicated to the member’s overall well-being.

• Clackamas County• Hood River County• Multnomah County• Washington County• The city of Newberg

in Yamhill County

A Portland-area network with more than 70 medical home clinics in Washington, Multnomah, Clackamas and Hood River counties, and the city of Newberg in Yamhill County, all designated as medical homes for providing patient-focused, coordinated and affordable care.


PLAN FEATURES:


deductible waived and covered in full • Integrated and coordinated care delivered by a network of Providence physicians• Referrals coordinated by a dedicated medical home team





$15/$30 20%/40% $2,000 $500

$25/$50 30%/50% $2,500 $1,000

$35/$70 $3,000 $2,000

$3,500 $3,000

$4,000 $4,000

$6,350

$7,900

Connect Plans: Benefit HighlightsüNo deductible needs to be met prior to receiving this benefit$ Copay applies and % coinsurance appliesCIF Covered in fullA referral from your medical home is required to receive in-network benefits



Express Care Virtual or Web-direct visits CIF ü Not coveredVirtual visits to a specialist by phone and video $15 to $55ü Not covered


Periodic health exams and well-baby care CIF ü 40% to 50% Routine immunizations and shots CIF ü 40% to 50%Colonoscopy (age 50+) CIF ü 40% to 50% Gynecologic exams, pap tests CIF ü 40% to 50% Mammograms CIF ü 40% to 50%Tobacco cessation, counseling/classes and deterrent medications CIF ü Not covered


Office visits to a PCP $15 to $35/visit ü 40% to 50%Office visits to alternative care providers $15 to $35/visit ü 40% to 50%Office visits to specialists/other providers $30 to $70/visitü 40% to 50%Allergy shots and serums 20% to 30%ü 40% to 50%Infusions and injectable medications 20% to 30% 40% to 50%Surgery, anesthesia in an office or facility 20% to 30% 40% to 50%

Diagnostic Services

Lab and X-ray services 20% to 30% ü 40% to 50%High-tech imaging services (such as PET, CT, MRI) 20% to 30% 40% to 50%



$250 $250

Urgent care services (for non-life-threatening illness/minor injury) $30 to $70/visit ü 40% to 50% Emergency medical transportation (air and/or ground) 20% to 30% 20% to 30%

Hospital Services


Outpatient Services

Outpatient infusion, dialysis, chemotherapy, radiation 20% to 30% 40% to 50%Temporomandibular joint (TMJ) services 50% Not coveredOutpatient rehabilitative physical therapy 20% to 30%ü 40% to 50%Outpatient rehabilitative occupational or speech therapy 20% to 30% 40% to 50%

Maternity Services

Prenatal office visits CIF ü 40% to 50%Delivery and postnatal services (PCP or certified nurse midwife) 10% to 20% 40% to 50%Delivery and postnatal services (OB/GYN physician/provider, all other licensed providers)

20% to 30% 40% to 50%

Inpatient hospital/facility services 20% to 30% 40% to 50%Routine newborn nursery care 20% to 30% 40% to 50%


PLAN FEATURES:


deductible waived and covered in full. • Integrated and coordinated delivered by a network of recognized physicians• Referrals coordinated care by a dedicated medical home team


• Ideal for cost-conscious employers looking to offer comprehensive and affordable health insurance to employees

• A medical home approach to care with access to conveniently located clinics and hospitals in Oregon and southwest Washington

• Members work closely with a dedicated medical home care team developing a personal care experience that takes the hassle out of health care

• Substantial premium savings• A tailored network with nearly 300 primary care clinics recognized for providing

patient-focused, coordinated and affordable care


In Network PCP/Specialist Copays

In/Out-of-Network Coinsurance

In Network OOP Max In Network Deductible

$20/$40 20%/40% $4,000 $1,500

$25/$50 30%/50% $7,900 $3,000

Choice Plans

Choice plans combine a medical home model of care with a tailored provider network. Care is coordinated by a team of health professionals uniquely dedicated to patient’s overall well-being. Members select a recognized medical home from the Providence Choice Network. The medical home team supports all aspects of a member’s health from wellness and prevention to active management of chronic conditions.

Nearly 300 medical home clinics in Oregon and southwest Washington designated as medical homes for providing patient-focused, coordinated and affordable care.

• Baker• Benton• Clackamas• Clark (WA)• Coos• Crook• Curry • Deschutes

• Douglas• Hood River • Josephine• Klamath• Lane• Lincoln• Linn• Malheur

• Marion• Multnomah• Polk• Umatilla• Union• Wallowa• Washington• Yamhill


PLAN FEATURES:


deductible waived and covered in full. • Integrated and coordinated delivered by a network of recognized physicians• Referrals coordinated care by a dedicated medical home team


In Network PCP/Specialist Copays

In/Out-of-Network Coinsurance

In Network OOP Max In Network Deductible

$20/$40 20%/40% $4,000 $1,500

$25/$50 30%/50% $7,900 $3,000

Choice Plans: Benefit Highlights


In-network copay or coinsurance from your medical home with a

referral

Out-of-network copay or coinsurance from a

non-network provider or without a referral


Express Care Virtual or Web-direct visits CIF ü Not coveredVirtual visits to a specialist by phone and video $25 to $35/visit ü Not covered


Periodic health exams and well-baby care CIF ü 40% to 50%Routine immunizations and shots CIF ü 40% to 50%Colonoscopy (age 50+) CIF ü 40% to 50%Gynecologic exams, pap tests CIF ü 40% to 50%Mammograms CIF ü 40% to 50%Tobacco cessation, counseling/classes and deterrent medications CIF ü Not covered


Office visits to a PCP $20 to $25/visit ü 40% to 50%

Office visits to alternative care providers $20 to $25/visit ü 40% to 50%Office visits to specialists $40 to $50/visit ü 40% to 50%Allergy shots and serums 20% to 30% ü 40% to 50%Infusions and injectable medications 20% to 30% 40% to 50%

Diagnostic Services

Lab and X-ray services 20% to 30% ü 40% to 50%High-tech imaging services (such as PET, CT or MRI) 20% to 30% 40% to 50%



$250 $250

Urgent care services (for non-life-threatening illness/minor injury) $40 to $50/visit ü 40% to 50%Emergency medical transportation (air and/or ground) 20% to 30% 20% to 30%

Hospital Services


Outpatient Services

Outpatient infusion, dialysis, chemotherapy, radiation 20% to 30% 40% to 50%Temporomandibular joint (TMJ) services 50% Not coveredOutpatient rehabilitative physical therapy 20% to 30%ü 40% to 50%Outpatient rehabilitative occupational or speech therapy 20% to 30% 40% to 50%

Maternity Services


20% to 30% 40% to 50%


PLAN FEATURES:

• ACA preventive medications obtained by prescriptions are covered in full.• Newly enrolled members have access to a 90-day transition period for most

prescriptions that normally require prior authorization.• Prescription cost shares apply toward the medical plan out-of-pocket maximum.• Covered benefits are included for preferred generics, non-preferred generics,

preferred brand-name drugs, non-preferred brand-name drugs and specialty drugs.• A 90-day supply of maintenance medications is two times the 30-day supply copay on all

pharmacy plans when purchased at a preferred retail or preferred mail order pharmacy.• Compounded drugs are covered at 50% coinsurance for up to a 30-day supply when

purchased at a participating retail or preferred retail pharmacy.

PRESCRIPTION DRUG FORMULARIES:

The Providence Formulary is a list of FDA-approved prescription brand-name and generic drugs developed by physicians and pharmacists. It is designed to offer drug treatment choices for covered medical conditions.

The Formulary can help members and their physician choose effective medications that are less costly and minimize out-of-pocket expenses.

Some prescription drugs require prior authorization or a formulary exception in order to be covered; these may include select formulary agents, non-formulary agents, step therapy and/or quantity limits as listed in the prescription drug formulary available on our website. If a formulary exception is approved, generic or brand-name cost share will apply.

Effective generic drug choices are available to treat most medical conditions.

PLAN DESIGN OPTIONS: Pharmacy Plan

Preferred generic drugs

Non-preferred generic drugs

Preferred brand-name

drugs

Non-preferred brand-name

drugs

Specialty drugs

Rx 10/15/30/60/50 $10 $15 $30 $60 50% up to $200

Rx 10/15/45/75/50 $10 $15 $45 $75 50% up to $200

Rx 10/15/60/80/50 $10 $15 $60 $80 50% up to $200

Rx 15/20/75/100/50 $15 $20 $75 $100 50%

Rx 15/20/50/50/50 $15 $20 50% 50% 50%

Rx 15/15/30/30/30 $15 $15 $30 $30 $30

Rx 15/15/45/45/45 $15 $15 $45 $45 $45

• Cost shares shown are for up to a 30-day supply purchased at a participating/preferred retail or specialty pharmacy.• Mail order benefits are available on all pharmacy plans. A 90-day supply of maintenance medication is available when purchased at a preferred retail

or preferred mail order pharmacy.• A 90-day supply of maintenance medication is two times the 30-day supply copay on all pharmacy plans when purchased at a preferred retail or

preferred mail order pharmacy.

Pharmacy PlansSupplement your medical coverage with the appropriate pharmacy plan. These plans include a comprehensive prescription drug formulary. Providence actively takes steps to mitigate the impact of increasing drug costs while ensuring that members continue to have access to safe, effective and affordable medications.


ALTERNATIVE CARE PLAN OPTIONS (CHA PLANS):

• Chiropractic Manipulation and Acupuncture (standard CHA) plans• Chiropractic Manipulation and Acupuncture Plus (CHA Plus) plans

Standard CHA plans provide benefits for medically necessary chiropractic and acupuncture services from in-network licensed providers. CHA Plus plans offer the same benefits and coverage from any licensed provider.

PLAN FEATURES:

• No provider referral is required• No deductible needs to be met*• Massage therapy can be added as an option• Copays do not apply toward the medical plan out-of-pocket maximum• In Washington, copays and deductibles apply to toward the medical out-of-pocket

maximum.

*Except with HSA Qualified plans

Standard CHA and CHA Plus plan options are available with the following copay and benefit combinations:


Copays Maximum per member calendar year benefit

$15 $500

$25 $1,000

$1,500

Chiropractic Manipulation and Acupuncture PlansComplementary and alternative medicine benefits are valued employee benefits that can sup-port health and wellness. Our Alternative Care options offer employees therapeutic benefits that are integrated with our traditional care pathways.


Vision Plans

KEY PLAN FEATURES:

• No deductible• An annual eye exam from participating providers after a $10 copay• Basic lenses for adults covered in full; $130 allowance toward frames or contacts*• Progressive lenses are available with a $50 copay• For children up to age 19, full coverage for eye exam, lenses and frames every

12 months with no copay (hardware is not covered for pediatrics on the Vision Exam plan)**

• No referral required (out-of-pocket costs generally will be less with an in-network provider)

• Discounts on additional exams, extra features and options, such as lens tinting and nonprescription sunglasses

*Except for the Vision Exam plan which does not cover frames or lenses

**For members on a vision plan featuring Otis and Piper Eyewear, any frame from Otis and Piper Eyewear or the equivalent value can be applied toward any other frame.


Vision PlanExam

FrequencyLens

FrequencyFrame

FrequencyExam Copay

Adult Frame or

Contact Lens Allowance

Vision Exam 12 months N/A N/A $10 N/A

Vision Basic 12 months 24 months 24 months $10 $130

Vision Basic featuring Otis and Piper Eyewear

12 months 24 months 24 months $10 $130

Vision Plus 12 months 12 months 24 months $10 $130

Vision Plus featuring Otis and Piper Eyewear


Vision Premium 12 months 12 months 12 months $10 $130

Vision Premium featuring Otis and Piper Eyewear


Providence partners with VSP to offer seven vision plan options featuring the VSP Choice

provider network.


Providence Dental Plans

KEY PLAN FEATURES:

• Plan options available with or without orthodontia benefits.• Flexible enrollment, so employees have full ability to select coverage for

dependents who need it.• Robust coverage for services received in- and out-of-network.• No waiting period for in- or out-of-network.• No deductible for in- and out-of-network diagnostic and preventive services.• In-network diagnostic and preventive services are covered in full.• Diagnostic and preventive services do not apply toward calendar year benefit

maximum.

DENTAL PLAN OPTIONS:

Plans with Plus in the name indicate that orthodontia coverage is included.

DENTAL QUOTE ASSUMPTIONS (SHELF RATES):

Shelf rates are valid for up to 200 subscribers.Must comply with the first three Medical Underwriting Requirements.

• Quoted rates and requirements are based upon the census and other information provided to PHP by the producer and/or group. In the event of material changes or errors in the information provided, PHP reserves the right to modify the quoted rates and requirements.

• Group must qualify as a large employer with primary legal situs in the state of issue.• Products are offered on a sole carrier basis only; and PHP reserves the right to quote only

on a sole carrier basis. If medical and dental enrollment match, minimum contribution requirements are waived and participation requirements defer to the medical.

• If medical and dental enrollment do not match, subscriber level enrollment may vary between medical and dental. A subscriber has three choices: 1. Enrolling on medical and dental with matching dependent enrollment; 2. Enrolling on medical only with no dental; 3. Enrolling on dental only, with no medical.

• A group may implement at most one shelf plan design (multiple plan options not allowed).

• Dental products are offered on a sole carrier basis. • Any exceptions to the quote assumptions above are subject to underwriting review.• Must be employer-sponsored coverage (contract is with the employer not the employees).• Shelf rates are not valid for associations, PEO’s, dental offices, or unions/

multi-employer trusts.• No carve-outs allowed for shelf rates (e.g., retirees only, management only, etc.).

Providence Dental Plans provide comprehensive benefits that help promote overall good health and are available when paired with a Providence medical plan. The Providence Dental Plan options are available with or without orthodontia benefits. Members have access to more than 2,300 in-network dental providers in Oregon and southwest Washington and more than 270,000 in-network provider listings nationwide.


Providence Dental Plans: Benefit Highlights

Preventive Dental

Essential Dental

Essential Access

Advantage Access 2000

Advantage Access 1500

In- network

Out-of-network

In- network

Out-of-network

In- network

Out-of-network

In- network

Out-of-network

In- network

Out-of-network

Deductible None$50 per person $150 per family

(3 or more)

$50 per person $150 per family

(3 or more)


(3 or more)


(3 or more)

Benefit maximum None $1,000 $1,000 $2,000 $1,500

Diagnostic and Preventive services (includes routine exams, cleanings, bitewing X-rays, topical fluoride [age 16 and younger], space maintainers)

CIF CIF ü 10% ü CIF ü 10% ü CIF ü CIF ü

Basic services (includes restorative fillings, oral surgery, endodontics, periodontics)

Not covered 20% 30% 20% 30% 20% 20%

Major services (includes crowns, dentures, bridge work)

Not covered 50% 60% 50% 50% 50% 50% 50% 50%

Orthodontics (Plus Plans)

In- network

Out-of-network

In- network

Out-of-network

In- network

Out-of-network

In- network

Out-of-network

In- network

Out-of-network

Common lifetime maximum

NA $1,500 $1,500 $1,500 $1,500

Adult NA50% up to

$1,50050% up to

$1,50050% up to

$1,50050% up to

$1,500

Children NA50% up to

$1,50050% up to

$1,50050% up to

$1,50050% up to

$1,500

Reimbursement MAC MAC MAC MAC MAC UCR MAC UCR MAC UCR

All plan benefits are based on a calendar year. After meeting the deductible, the member pays the following amounts for covered services. The deductible does not apply to some covered services. They are marked with ü.


Important Contact Information2019 large group benefit summaries ProvidenceHealthPlan.com

Express Care Clinics and Express Care Virtual Providence.org/expresscare

Employer website ProvidenceHealthPlan.com/employers

HealthEquity HealthEquity.com/providence

Health and wellness for members ProvidenceHealthPlan.com/findyourfit

myProvidence myProvidence.com

Pharmacy resources ProvidenceHealthPlan.com/pharmacy

Producer compensation, news and notices ProvidenceHealthPlan.com/producernotices

Producer website ProvidenceHealthPlan.com/producers

Providence creditable coverage ProvidenceHealthPlan.com/2019creditable

Providence Dental ProvidenceHealthPlan.com/largegroupdental

Providence Employee Assistance Program ProvidenceHealthPlan.com/eap

Providence Health Coaching ProvidenceHealthPlan.com/healthcoach

Provider directory ProvidenceHealthPlan.com/findaprovider


Our MissionAs expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

Our ValuesCompassion

Dignity

Justice

Excellence

Integrity

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PHP19-029_Large Group Plan Overview 03/19

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Documents

2019 Plan Overview - Providence Health Plan/media/Files...This guide gives you an overview of Providence Health Plan’s 2019 large group products, all designed to meet the unique