my healthHaving health plan coverage is important for managing your most important asset: your health.

my health planChoosing health care with Providence Individual and Family Plans means you can manage your health and financial future with confidence.

Providence Health Plan is an exclusive provider organization plan offered by Providence Health System. The organization includes a network of hospitals, clinics, urgent care centers, physicians, health plans and other health care providers.

togetherWe’re more than a health plan. We’re part of Providence Health System, where serving the needs of people in the Northwest has been our mission since 1856.

we appreciate your interest in our individual and family plans.

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getting startedwhy choose Providence Individual & Family plans

types of coveragechoose coverage for yourself, your family or just your children

plan features - Optimum, Value & HSAcompare the coverage options for the plans we offer

monthly premiumsa chart listing premiums for each plan

medical benefit comparisondeductible, copay and coinsurance amounts

extra values & discountsdiscounts and services exclusively for members

health plan basicsunderstand our health care coverage and benefits

benefit limitations and exclusions a list of covered services that have limited benefits

frequently asked questionshelpful answers to common questions

helpful definitionsdefinitions and terms used in this booklet

service area mapwhere members must live to apply for coverage

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welcome

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compare plans. get a quote. apply now.www.providence.org/healthplans

getting started

This booklet provides an overview of our Individual and Family plans. For specific information about plan benefits, enrollment requirements, limitations and exclusions, please refer to the Plan Contract, the legal agreement between you and Providence Health Plan. The Plan Contract and Summary of Benefits are available online at www.providence.org/healthplans or call our Sales Department at 503-574-5000 or 1-800-988-0088 to request that these documents be mailed to you.

n $20 copay for preventive health care services for men, women and children without meeting the deductible first.

n An extensive provider network with more than 8,000 providers, hospitals and clinics in Oregon and southwest Washington.

n Prescription drug coverage included in all plan designs.

n Chiropractic benefits.

n Extra values with vision, hearing, recreation and alternative care discounts.

n 24-hour medical advice line.

n Online services such as medical and claims information.

n Financial stability, as Providence Health Plan is the only provider-sponsored health plan in the United States with an “A” rating by A.M. Best Company, the world’s most authoritative insurance rating source.

With a variety of plan options, comprehensive coverage and extra values, Providence Individual and Family Plans can offer you more value for your health care dollar.

Questions?

Call Providence Health Plan Sales Department: 503-574-5000 or 1-800-988-0088Monday – Friday from 8 a.m. to 6 p.m. Our office is located at: 3601 SW Murray Blvd, Suite 10, Beaverton, OR 97005

Providing comprehensive coverage and true value, our plans offer:

types of coverage

Individual Coverage

To apply for individual plan coverage, you must:

n be 18-64 years of age

n not eligible for Medicare and

n live in the Oregon service area (page 18).

Apply for individual coverage. You will be on an individual plan. This means you will be the only person covered on the plan and you will be “the plan policyholder.” Your monthly premium is determined by your age and the type of plan you choose.

Family

Individual

Family

Child-Only

Family Coverage

A family plan can include:

n you and your spouse (ages 18-64, must live in Oregon Service area, page 18)

n you and your dependent children (age 0-22); or

n you, your spouse or domestic partner and your dependent children.

Apply for family plan coverage. The premium is determined by the oldest family member applying for coverage.

Child-Only Coverage

To apply for dependent-only coverage, your child must:

n be newborn to 17 years of age

n live in the Oregon service area (page 18)

Coverage just for children: If you are looking for coverage only for your dependent children, you can apply as the plan policyholder for your dependent child’s coverage. You must apply for a separate policy for each person age 0-17. See the monthly premium chart (page 12) age “0-17” to determine the monthly premium for each child.

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Optimum Plans offer you the most comprehensive coverage. You receive women’s and men’s preventive care services, personal physician/provider office visits and specialist visits for $20 copay, before meeting the deductible. That means you don’t have to pay your deductible before you get medical advice that can keep you well. If you choose to see a non-participating provider, you’ll pay 40 percent coinsurance. There are five Optimum Plans with several deductible amounts to choose from.

Value Plans offer similar coverage as Optimum Plans with women’s and men’s preventive care services and personal physician/provider office visits for $20 copay, before deductible. However, the deductible is not waived for specialist office visits. After deductible, specialist visits are 30 percent coinsurance for participating or 50 percent coinsurance for non-participating specialist office visits. There are five Value Plans with several deductible amounts to choose from.

plan features – Optimum, Value and HSA

Find the right health plan – one that meets the needs of you or your family, as well as your budget.

Choose between three health plan options, Optimum, Value or HSA, each with a variety of features and deductibles to meet your needs.

Both Optimum and Value plans feature:

n An accidental injury benefit for all covered services (except chiropractor office visits), before meeting deductible.

n Hospital, surgery, X-ray, laboratory services from participating providers and health care facilities.

n Chiropractic office visits (In-Plan) for $20 copay, after meeting deductible.

n Emergency care (In-Plan and Out-of-Plan) for a $125 copayment, before meeting deductible.

n Out-of-Plan benefit. See non-participating providers for covered services and pay a coinsurance amount.

n Prescription drugs through participating pharamcies for generic and brand-name drugs. Deductible does not apply.

n Travel Benefits and Nationwide coverage through our national network of participating providers.

Our HSA Plans work together with a Health Savings Account (page 7) and provide comprehensive coverage with a low monthly premium, while you set aside tax-deductible, interest-earning funds in a health savings account (HSA) to help cover your deductible and other qualified medical expenses. By rolling over unused funds from year to year, you also enjoy tax-sheltered investment and retirement planning options.

HSA plans feature:

n Preventive care (In-Plan), before meeting deductible.

n Annual gynecological exams and mammograms (In-Plan), before meeting deductible.

n Personal physician/provider office visits (In-Plan) for $20 copayment, after meeting deductible.

n Specialist office visits, hospital, surgery, X-ray, laboratory (In-Plan) for 20 percent coinsurance, after meeting deductible.

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HSA features cont:

n Emergency care (In-Plan and Out-of-Plan) for $125 copay, after meeting deductible.

n Urgent care and ambulance services for 20 percent coinsurance, after meeting deductible.

n Chiropractor office visits (In-Plan) for $20 copay, after meeting deductible.

n Out-of-Plan benefit. See non-participating providers for 40 percent coinsurance, after meeting deductible.

n Prescription drugs through participating pharmacies for generic and brand-name drugs, after meeting deductible.

n Travel Benefits and Nationwide coverage through our national network of participating providers.

Your Health Savings Account (HSA)

When you enroll in a HSA Plan, you can start a health savings account (HSA). An HSA is funded by your contributions and allows you to save funds for future medical expenses and/or retirement. You can contribute up to the maximum levels determined by the Internal Revenue Service each year.

You can choose the bank or financial institution that will administer your HSA. Providence Health Plan has partnered with U.S. Bank to help establish and administer HSA’s. U.S. Bank provides:

n Monthly statements, either paper or online, showing your account activity.

n Online and toll-free access to account information.

n Mutual fund investment options for a portion of your HSA funds.

n An HSA debit card and checks for easy payment of qualified medical expenses. View the list of qualified medical expenses at the Internal Revenue Service’s Web site: www.irs.gov

For more information about HSA’s, visit the U.S. Treasury Web site at www.treas.gov, search “HSA”.

Need help choosing your ideal plan?

To help you choose a plan that meets your needs, we’ve described some preferences below that may apply to you. Consider the suggested plan types that emphasize features most important for you.

I want low monthly payments with basic preventive care and coverage for major medical expenses.

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Consider: Optimum 5000

Value 7500Optimum 10000

I want to pay as little as possible before my plan begins covering medical expenses.

}}

Consider: Optimum 500

Value 500Optimum 1000

I want a balance of affordable premiums and quality health coverage, low-cost doctor visits and prescription benefits.

}}

Consider: Optimum 500

Optimum 2500Value 2500

I want a plan with tax-advantages (health savings account) that allows me to save for future medical expenses.

}}Consider: HSA 1200HSA 2500

I want a plan with low fees for doctor visits, prescription benefits and preventive care for my entire family.

}}Consider:

Optimum 500Value 500

I want coverage only for my kids and the ability to see a doctor frequently with predictable costs.

}}Consider:

Optimum 500Optimum 1000

monthly premiums

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Providence individual & family plansnov. 1, 2007 – oct. 31 2008

* These plans are eligible for premium assistance through FHIAP. See page 12 or www.providence.org/healthplans for details. To determine premium, use the age of the oldest covered family member.

Optimum Plans

Age 0 - 17 18 - 20 21 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64

Optimum 500* Individual $91 $118 $142 $153 $174 $186 $238 $280 $326 $392 $449 Individual&Spouse $237 $284 $306 $348 $373 $475 $561 $651 $784 $899 Individual&Children $178 $213 $230 $261 $280 $357 $421 $488 $588 $674 Individual&Family $332 $397 $452 $523 $550 $689 $701 $749 $901 $989Optimum 1000* Individual $84 $109 $131 $141 $161 $172 $219 $259 $300 $362 $414 Individual&Spouse $218 $262 $283 $321 $344 $439 $517 $601 $723 $829 Individual&Children $164 $196 $212 $241 $258 $329 $388 $451 $542 $622 Individual&Family $306 $367 $417 $482 $507 $636 $647 $691 $831 $912Optimum 2500 Individual $70 $90 $108 $117 $133 $142 $182 $214 $249 $300 $343 Individual&Spouse $181 $217 $234 $266 $285 $363 $429 $498 $599 $687 Individual&Children $136 $163 $176 $200 $214 $272 $321 $373 $449 $515 Individual&Family $253 $304 $345 $399 $420 $527 $536 $572 $689 $755Optimum 5000 Individual $59 $77 $92 $99 $113 $120 $154 $181 $211 $253 $290 Individual&Spouse $153 $184 $198 $225 $241 $307 $363 $421 $507 $581 Individual&Children $115 $138 $149 $169 $181 $231 $272 $316 $380 $436 Individual&Family $214 $257 $292 $338 $355 $446 $453 $484 $583 $639Optimum 10000 Individual $47 $61 $73 $79 $89 $96 $122 $144 $167 $201 $231 Individual&Spouse $122 $146 $157 $179 $191 $244 $288 $334 $402 $461 Individual&Children $91 $109 $118 $134 $143 $183 $216 $251 $302 $346 Individual&Family $170 $204 $232 $268 $282 $354 $360 $384 $462 $507

Value PlansAge 0 - 17 18 - 20 21 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64

Value 500* Individual $85 $111 $132 $143 $163 $174 $222 $262 $304 $366 $419 Individual&Spouse $221 $265 $286 $325 $348 $444 $523 $608 $731 $839 Individual&Children $166 $199 $215 $244 $261 $333 $392 $456 $549 $629 Individual&Family $309 $371 $422 $488 $513 $643 $654 $699 $841 $923Value 1000 Individual $77 $100 $120 $129 $147 $157 $201 $237 $275 $331 $379 Individual&Spouse $200 $240 $259 $294 $314 $401 $473 $549 $661 $758 Individual&Children $150 $180 $194 $220 $236 $301 $355 $412 $496 $569 Individual&Family $280 $335 $381 $441 $464 $582 $591 $632 $760 $834Value 2500 Individual $64 $82 $99 $107 $121 $130 $166 $195 $227 $273 $313 Individual&Spouse $165 $198 $213 $242 $259 $331 $391 $453 $546 $626 Individual&Children $124 $148 $160 $182 $195 $248 $293 $340 $409 $469 Individual&Family $231 $277 $315 $364 $383 $480 $488 $522 $627 $688Value 5000 Individual $52 $68 $81 $87 $99 $106 $136 $160 $186 $224 $257 Individual&Spouse $135 $162 $175 $199 $213 $271 $320 $372 $447 $513 Individual&Children $101 $122 $131 $149 $160 $204 $240 $279 $336 $385 Individual&Family $189 $227 $258 $298 $314 $394 $400 $428 $515 $564Value 7500 Individual $44 $57 $68 $73 $83 $89 $114 $134 $156 $187 $215 Individual&Spouse $113 $136 $146 $166 $178 $227 $268 $311 $374 $429 Individual&Children $85 $102 $110 $125 $134 $170 $201 $233 $281 $322 Individual&Family $158 $190 $216 $250 $263 $329 $335 $358 $430 $472

HSA Plans

Age 0 - 17 18 - 20 21 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64

HSA 1200 Individual $89 $116 $139 $150 $171 $182 $233 $274 $319 $384 $440 Individual&Spouse $217 $261 $281 $320 $342 $437 $515 $598 $720 $825 Individual&Children $163 $196 $211 $240 $257 $327 $386 $449 $540 $619 Individual&Family $305 $365 $415 $480 $505 $633 $644 $688 $828 $908HSA 2500 Individual $75 $97 $116 $125 $142 $152 $194 $229 $266 $320 $367 Individual&Spouse $180 $216 $233 $265 $283 $362 $427 $495 $596 $683 Individual&Children $135 $162 $175 $199 $213 $271 $320 $371 $447 $513 Individual&Family $252 $302 $344 $397 $418 $524 $533 $570 $685 $752

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Optimum Plans Value Plans HSA PlansAnnual Deductible Individualdeductible/familydeductible

Optimum500$500/$1,500Optimum1000$1,000/$3,000Optimum2500$2,500/$7,500Optimum5000$5,000/$15,000Optimum10000$10,000/$30,000

Value500$500/$1,500Value1000$1,000/$3,000Value2500$2,500/$7,500Value5000$5,000/$15,000Value7500$7,500/$22,500

HSA1200$1,200/$2,400HSA2500$2,500/$5,000

Annual Out-of-Pocket MaximumIndividualout-of-pocketmaximum/familyout-of-pocketmaximum

AllOptimumPlans:$2,500/$7,500

Value500$4,000/$12,000Value1000$4,500/$13,500Value2500$5,500/$16,500Value5000$8,500/$25,500Value7500$11,000/$33,000

HSA1200$5,250/$10,500HSA2500$5,000/$10,000

Lifetime Maximum $2millionperperson $2millionperperson $2millionperperson

Accidental Injury Benefit Doesnotapply

After meeting your deductible, you pay the following amounts for covered services: (The deductible is waived for some covered services. These services are marked with t)

Preventive Care In-Plan Out-of-Plan In-Plan Out-of-Plan In-Plan Out-of-Plan

Periodichealthexams,well-babycare

$20copayt 40%t $20copayt 50%t $20copayt 40%

Women’sannual(calendaryear)gynecologicalexam

$20copayt 40%t $20copayt 50%t $20copayt 40%

Follow-upvisitsafterannualgynecologicalexam

$20copayt 40%t $20copay 50% $20copay 40%

Mammograms $20copayt 40% $20copayt 50% $20copayt 40%

Physician/Provider Services

Officevisitstoapersonalphysician/provider

$20copayt 40%t $20copayt 50%t $20copay 40%

Officevisitstoachiropractor* $20copay Notcovered $20copay Notcovered $20copay Notcovered

Officevisitstospecialists $20copayt 40%t 30% 50% 20% 40%

Otherservices,includinginpatienthospitalvisits 20% 40% 30% 50% 20% 40%

Routineimmunizations/shots $20copayt 40%t $20copayt 50%t $20copayt 40%

Hospital Services

Acutecare20% 40% 30% 50% 20% 40%

Skillednursingfacility*

Maternity Care

Provider&hospitalservices 20% 40% 30% 50% 20% 40%

Emergent/Urgent care

Emergencyservices $125copayt $125copayt $125copay

Urgentcareservices20% 30% 20%

Ambulanceservices*

Other Covered Services

Durablemedicalequipment&medicalsupplies*

20% 40% 30% 50% 20% 40%

Rehabilitativecare&services*

Lab&x-ray,outpatientsurgery,radiationtherapy,chemotherapy

Homehealthcare*

Mentalhealth&alcoholtreatment*

Prescription Drugs

Coveredatparticipatingretailandmail-orderpharmaciesonly

Generic drugs - $10t

Brand-name drugs – �0%tGeneric & Brand drugs – �0%t Generic & Brand drugs – �0%

t Deductible is waived. This means you can receive coverage for these services prior to meeting your deductible.

* Limitations apply. See page 14 or Plan Contract for details.

Providence individual & family plans

Thedeductibleiswaivedforallcoveredservices,exceptchiropracticservices,requiredtotreatanaccidentalinjurywithin90daysofinjury

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Extra values and discount programs:

n LifeBalance Program offers exclusive discounts on recreational, cultural and wellness activities throughout the Northwest. Save on fitness club memberships, musical events and access special member events, such as white-water rafting, ski trips, theater nights, and sporting events.

n American Specialty Networks Affinity Access Program offers discounts on acupuncture, chiropractic care, massage therapy and dietitian services. Use a credentialed network of providers while paying 25 percent less than the participating provider’s usual and customary fees.

n Providence Health & Fitness classes offer members discounts on classes to help lose weight, stop smoking, be a better parent or just have fun!

n Providence RN – A free, 24-hour medical advice line. Members may call with health-related questions and speak to a registered nurse, 24 hours a day, seven days a week.

n TruVision offers discounts on laser vision correction, contact lenses, and eyeglasses in Oregon and southwest Washington.

n TruHearing offers digital hearing aids at a reduced price for members, their parents and their grandparents.

n Find Health Resources at www.providence.org/healthplans for medical information, preventive screenings, pharmacy resources and more.

extra values and discounts

Get more value from your Providence Individual and Family Plan benefits!

In addition to your medical benefits and coverage, our extra value and discount programs offers you a wide range of products and services for you and your family to stay healthy and live well!

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Individual and Family Plan Service Area

ready to apply?

Enrolling information:Please be thorough and accurate in completing your application. If you provide health information in error or omit information about your health, we may need to terminate your contract and/or not cover your medical claims.

When you apply and accept our offer of coverage, we will send your Plan Contract and Summary of Benefits. If you decide to decline coverage, notify us in writing within 10 days of receiving your contract, and we will refund your first month’s premium in full. The contract for coverage will be considered void.

Apply for a Providence Individual & Family Plan

Before you apply:Gather the following information for you and your family members listed on your application:

n Address, telephone numbers and other contact information

n Height and weight

n Date of birth

n Last four digits of Social Security number

n Information on medical conditions

n List of medications

n Name, address and telephone number of your physicians.

Select a plan and apply:

n Review the medical benefit comparison (page 9) and compare benefit options of each plan.

n Select the plan and deductible that is best for you.

n Review the monthly premium rate sheet for your plan selection (page 8) to determine your monthly premium.

n Apply online at www.providence.org/healthplans or fill out a paper application.

n Complete the Health Statement for yourself and each family member you want to enroll.

n Submit your application online or send it to us by mail.

Questions?Visit us online at www.providence.org/healthplans or call our Sales Department at 503-574-5000 or 1-800-988-0088.

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Preventive CareWe believe that getting the right preventive care is essential for maintaining good health. All our plans cover preventive care prior to meeting your deductible.

Here’s a list of preventive care services we cover:n Well baby care

n Periodic health examinations

n Immunizations/shots

n Annual women’s health care exams

n Mammograms

n Men’s and women’s preventive care

n Prostate screening exams

n Colorectal screening exams

We cover periodic health examinations and well-baby care according to the following schedule.

Infants up to 2� months Upto8well-babyvisits

Children2yearsthrough6years7yearsthrough19years

OneexameveryyearOneexamevery2years

Adults20yearsthrough29years30yearsthrough49years50yearsandolder

Oneexamevery5yearsOneexamevery2yearsOneexameveryyear

Women’s careGynecologicalexam–includesbreast,pelvicandPapexamination

Oneexameveryyear

MammogramsWomen40andolder

Onceeverycalendaryearunlessdesignatedhighrisk.

Family Health Insurance Assistance Program (FHIAP)FHIAP is a program that helps uninsured individuals and families buy health insurance. FHIAP gives subsidies (grants of money) to pay 50 to 95 percent of your monthly premium, depending on your eligibility. Three Providence Individual & Family plans are FHIAP-eligible. To apply for a subsidy, call FHIAP at 1-888-564-9669 or visit www.fhiap.oregon.gov

Provider Network

Our plans encourage you to work closely with one personal physician/provider to provide your care, but you are not required to select one. Plus, you can see specialists any time without a referral.

You receive the highest level of benefits (called In-Plan) when you use participating providers for covered health care services. You also benefit from having coordinated care – meaning providers in our network bill us directly and work with us to arrange your care.

Our plans provide access to an extensive network of participating doctors, hospitals and other health care providers, including:

n More than 8,000 health care physicians and providers, including specialists, in Oregon and southwest Washington.

n More than 200 hospitals and facilities, including Providence Health System hospitals and Providence Medical Group clinics, in Oregon and southwest Washington.

n A national network of participating providers.

Is your doctor an Individual and Family Plan participating provider? Visit www.providence.org/healthplans and find our Provider Directory. Choose “Open Option Providers” as your search or call our Sales Department at 503-574-5000 or 1-800-988-0088.

Non-participating providers

There may be times when you want to see a doctor who is not a participating provider. When you see a non-participating provider (called Out-of- Plan), you will pay a higher coinsurance and your deductible on most services. Plus, you will pay any amounts over Usual, Customary, and Reasonable Rates (UCR). These rates are based on the service provided and the geographic location of the provider.

health plan basics

Getting the health care that’s right for you

Health care can be complex – but we can help. Here are basic definitions and explanations so you can get the most from your coverage and your care.

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Deductibles

An annual deductible is the amount you pay for covered services before the plan will begin to pay for these services. A new deductible must be met each calendar year. Deductible amounts are listed in the Plan Comparison (page 9).

Optimum Plan and Value Plan deductibles:

n Individual deductible – Once a member meets the individual deductible, the plan will begin paying for covered services for that member.

n Family deductible – Applies when three or more people are enrolled on a family plan. All amounts paid towards the individual deductible by a family member are counted towards the family deductible. Once the family deductible is met, the plan will begin paying for covered services for all enrolled family members. (Note: No member will ever pay more than the individual deductible before the plan begins paying for covered services for that member.)

n Deductible Carryover – For Optimum and Value Plans, deductible amounts applied in the last three months of a calendar year will carry forward and apply toward the deductible for the following year.

HSA Plan deductibles:

n Individual deductible – Once the individual deductible is met, the plan will begin paying for covered services.

n Family deductible – Once the family deductible is met, the plan will begin paying for covered services for all enrolled family members.

Choosing a plan that works best for you – one with a higher or lower deductible – is a decision that is unique to your own coverage needs:

n A higher deductible plan means a lower monthly premium. In exchange for a lower premium, you pay a larger amount for certain covered services before the plan will begin to pay for those services.

n A lower deductible plan means a higher monthly premium. However, the plan will begin to pay sooner for certain covered services.

Copayment & Coinsurance

After meeting your annual deductible, you and the health plan will begin to share the costs of covered health services through copayments and coinsurance.

n Copayment – Is a fixed dollar amount you pay for a covered service at the time care is provided.

n Coinsurance – Is a percentage of cost you pay for a covered service. Usually, your provider will bill you for your share of costs after care is provided.

Out-of-Pocket Maximum

To protect you from catastrophic costs, our plans include an annual out-of-pocket maximum. An out-of-pocket maximum is the total amount you pay for covered services, after deductible, in a calendar year. After you meet your out-of-pocket maximum, the plan will pay 100 percent of covered services for the remainder of the calendar year. (Certain services do not apply to the out-of-pocket maximum.) Our plans have different out-of-pocket maximums for individual plans and family plans. See the Plan Comparison (page 9) for details.

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Exclusion period

An exclusion period is the period of time specific treatments and services are not covered by the health plan.

n Pre-existing condition: A pre-existing condition is a medical condition for which medical advice, diagnosis, care or treatment was recommended or received within six months prior to the effective date of coverage. You must be on our plan for six months before treatment and services for a pre-existing condition will be covered.

n Elective procedures: An elective procedure is one that can be postponed for treatment during the limitation period. You must be on our plan for 12 months before treatment and services will be covered.

n Organ transplant: You must be on our plan for 24 months before we pay benefits for organ transplants.

n Newborns: Exclusion periods are waived for a newborn or adopted child if the child is enrolled on the plan within 60 days of birth or adoption placement.

Creditable Coverage

If you were covered on another health plan within 63 days before your effective date of coverage, you may have “creditable coverage.” Your creditable coverage will be applied month for month toward the plan exclusion periods. You will need to provide us with a copy of your Certificate of Creditable Coverage (obtain from your prior health carrier).

Limited Covered Services

Certain covered services have a coverage maximum for a set period of time. Limitations are set by either a maximum dollar or day/visit amount. Once the plan maximum is met, you will be responsible for costs until a new limitation period begins. The services below are subject to limitations and maximum coverage amounts.

Cover service Plan Maximum

RehabilitativeCareInpatientCare 30dayspercalendaryearOutpatientCare 30visitspercalendaryearSkilledNursingFacilityCare 60dayspercalendaryearHomeHealthCare 180visitspercalendaryearDurableMedicalEquipment, $2,500percalendaryear;Appliances, Orthoticsarelimitedto$200(The limit does not apply to percalendaryear other medical supplies, including diabetes supplies.) AmbulanceServices $2,000percalendaryearChiropracticCare 15visitspercalendaryear.MentalHealthTreatment $2,000percalendaryearforall services,inpatientoroutpatientAlcoholTreatment $4,500per2calendaryearsTransplantservices $250,000lifetimemaximumLifetimemaximumcoverage $2,000,000forallbenefits

benefit limitations and exclusions

Some benefit limitations and exclusions apply to all of our plans.

Benefit plans typically have exclusions and limitations – what the plans do not cover. The following is an overview of the most common exclusions and limitations that apply to our plans. Upon enrollment, you will be given a policy with a complete description of your coverage.

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Exclusions

n Alternative care, including massage, acupuncture and naturopathic care

n Chemical dependency, except as noted for alcohol treatment

n Cosmetic surgery, including prescription drugs

n Custodial care and private nursing services

n Dental care

n Experimental or investigational procedures, including prescription drugs

n Fertility/infertility treatment, services, supplies, prescription drugs

n Genetic testing

n Hearing aids/devices, screening and exams

n Home births and all related services

n Certain mental health services, including all residential/day treatment, treatment of developmental or learning disabilities; and self help programs, including family, marriage, sex and career counseling in the absence of illness.

n Physical exams primarily for camps, sports, insurance, licensing, employment, or other third-party purposes

n Sexual dysfunction or sexual transformation services, supplies or prescription drugs

n Voluntary sterilization or termination of pregnancy

n Temporomandibular joint (TMJ) services

n Treatment for tobacco addiction, including prescription drugs

n Vision services or supplies

n Obesity or weight control treatment, including surgery and prescription drugs

n Services for injury/illness sustained as a result of any work for wage or profit

n Services covered by motor vehicle insurance or other liability insurance

Prescription Drug Exclusions

n Drugs not listed in our plan formulary

n Drugs not directly related to treatment of a covered illness or injury

n Over-the-counter (OTC) drugs, medications, or vitamins and prescription drugs for which there are OTC therapeutic equivalents

n Drugs used in the treatment of fungal nail conditions

n Drugs used in the treatment of the common cold

n Intrauterine devices (IUDs) and diaphragms

n Amphetamines and derivatives, except for narcolepsy or hyperactivity treatment

n Drugs used to treat shift-sleep disorder, drug induced fatigue or general fatigue

n Fluoride, for members over the age of 10 years old

n Drugs to stimulate hair growth

n Most injectable medications must be purchased through Providence Home Infusion and are only covered if they are: intended for self-administration; labeled by FDA for self-administration; and on our list of “Self Administered Injectable Drugs.“ For a copy of this list, visit our Web site at www.providence.org/healthplans, or contact your Customer Service team

n Drugs that are placed on prescription-only status by federal or state mandate outside of required FDA-status assignment

Refer to the Plan Contract for additional information about exclusions and limitations or visit the Help Section on our Web site at www.providence.org/healthplans or call our Sales Department at 503-574-5000 or 1-800-988-0088. We can help if you have questions about plan benefits or exclusions.

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Who can apply for coverage? Oregon residents who live in our service area (page 18), are under age 65 and not eligible for Medicare.

Can I apply for coverage for my entire family? Yes. Eligible dependents include your spouse and unmarried dependent children under age 23. If a family member does not qualify as an eligible family dependent, he or she can apply on a separate individual plan.

Can my employer pay my premium? In compliance with Oregon state law, Providence Health Plan does not accept premiums from employers for individual health coverage.

Do I have coverage while I am at work? Our plans provide coverage 24 hours a day, seven days a week. You will be covered while you are working, unless you are required to have coverage through Workers’ Compensation Act or similar law.

Will my premium change? Premiums are subject to an annual rate change, usually in November. Your premium may change as you move to a new age category.

Will I be charged more if I use an insurance agent? No, your monthly premium is the same, whether or not you use an insurance agent. The agents we appoint to represent Providence Health Plan have thorough knowledge of the coverage we offer.

How do I pay for my coverage? We will invoice you for your first month’s premium once your application is approved and you accept our offer of coverage. Your premium is billed monthly, either by an automatic credit card payment or by mail.

When does my coverage begin? Coverage will begin either the first or 15th of the month following application approval. You can request a later date to begin coverage, up to 70 days from the date you submit your application.

How long will it take to process my application? If you apply online, you will be notified of your application status 1-5 business days from the date you submit online. If you apply by mail, you will be notified of your application status 7-10 business days from the date we receive it. If we request additional information to process your application, we notify you of the additional delay.

Are all applications for coverage approved? Not all applications are approved for coverage. Sometimes coverage is not offered, based on our review of your health statement.

What if you do not approve my application? If your application is not approved, you may be eligible for insurance through the Oregon Medical Insurance Pool (OMIP) at 1-800-848-7280 or www.omip.state.or.us/

Can I add a dependent after I’m enrolled? Yes. You can add your spouse or dependent children by completing a new application. If you add a newborn or adopted child within 60 days, you do not need to complete a new health statement.

How does Providence Health Plan protect my privacy? We respect the privacy of our members and applicants, and have policies regarding your protected health information:

n When you complete and sign your application, you agree that your health information may be released to determine eligibility for enrollment.

n Once enrolled for coverage, your agreement enables us to share your health information to administer your plan benefits and pay medical claims.

n We also may share information with your doctors or hospitals to provide medical care to you.

Please refer to our Notice of Privacy Practices for uses and disclosures of protected health information, including those required by law, at www.providence.org/healthplans or by calling our Sales Department.

frequently asked questions

Find answers to the most common questions here.

Have questions? Call us at 503-574-5000 or 1-800-988-0088, Monday-Friday, 8 a.m. to 6 p.m. We can help.

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A calendar year is January 1 through December 31.

Coinsurance is the percentage of cost that you must pay for a covered service.

A copayment is a dollar amount you must pay to a health care provider at the time you receive service.

A deductible is the amount you pay for certain covered services before the plan begins to pay for these services. A new deductible must be met each calendar year.

A dependent is a person who is supported by the policyholder or policyholder’s spouse.

Effective date of coverage is the date when coverage starts for a newly enrolled health plan member.

A lifetime maximum benfit is the total dollar amount of benefits payable under the Plan Contract during the lifetime of a member.

A member is a policyholder, eligible spouse or dependent who is enrolled in the plan.

A non-participating provider is a provider or facility with no agreement to participate with Providence Health Plan. When using non-participating providers you receive “Out-of-Plan” benefits.

A participating provider is a provider or facility with an agreement to participate with Providence Health Plan. When you use participating providers you receive “In-Plan” benefits and have less costs.

The Plan Contract is the legal agreement between the policyholder and Providence Health Plan, detailing plan benefits, enrollment requirements and information about your coverage.

A Policyholder is the person to whom the Plan Contract has been issued. A policyholder must be age 18 or older. If enrolling for dependent-only coverage, the parent/guardian applying will be the policyholder.

Premium is the monthly rate you pay for health plan coverage.

Pre-existing condition is any medical condition for which medical advice, diagnosis, care or treatment was recommended or received within six months prior to effective date of coverage.

Our service area is the geographic area in Oregon (page 18), where the policyholder, spouse of policyholder or child-only member must physically reside to qualify for coverage.

Summary of Benefits is a description of your plan benefits, copayments/coinsurance, deductibles and out-of-pocket maximums and is part of your Plan Contract.

Usual, Customary and Reasonable (UCR) describes charges for services provided by non-participating providers, UCR means charges billed by providers with similar training and experience.

helpful definitions

Definitions of health care terms used in this booklet.

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service area map

Service Area Zip Codes:

All zip codes in Benton, Clackamas, Columbia, Crook, Deschutes, Gilliam, Grant, Harney, Hood River, Jefferson, Linn, Marion, Multnomah, Polk, Sherman, Wasco, Washington, Wheeler and Yamhill counties.

Selected zip codes in Lane County: 97401, 97402, 97403, 97404, 97405, 97408, 97409, 97412, 97413, 97419, 97420, 97424, 97426, 97427, 97431, 97434, 97437, 97438, 97440, 97482, 97451, 97452, 97454, 97455, 97461, 97463, 97472, 97477, 97478, 97487, 97488, 97489, 98490, 97492.

Selected zip codes in Klamath County: 97425, 97733, 97737.