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Providence Health Plans of
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Plan Benefits:
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Plan Rates:
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Plan | Prime Plan | HSA Plan
Medical & Rx Limitations and Exclusions
Exclusion Periods
- Pre-existing condition: You must be covered on our plan for six months before a pre-existing condition will be covered. 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.
- Elective procedures: An elective procedure is one that can be postponed for treatment such as allergy testing or knee surgery. You must be on our plan for 12 months before treatment
for elective services will be covered.
- Organ transplant: You must be on our plan for 24 months before we pay benefits for organ transplants.
- 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 day for day 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).
Certain covered services have limitations. Once the plan maximum is met, you will be responsible for costs until a new limitation period begins. The following services are subject to limitations and
maximum coverage amounts:
| Cover service |
Plan Maximum |
| Rehabilitative Inpatient Care |
30 days per calendar year |
| Rehabilitative Outpatient Care |
30 visits per calendar year |
| Skilled Nursing Facility Care |
60 visits per calendar year |
| Home Health Care |
180 visits per calendar year |
| Durable Medical Equipment |
$2,500 per calendar year |
| Removable custom shoe orthotics |
$200 per calendar year |
| Emergency transportation |
$2,000 per calendar year |
| Mental Health Treatment |
$2,000 per calendar year |
| Alcohol Treatment |
$4,500 per 2 calendar years |
| Transplant services |
$250,000 lifetime maximum |
| Lifetime maximum coverage for all benefits |
$2,000,000 |
Medical Exclusions
The following is an overview of the most common exclusions that apply to our plans.
This list is not complete. Please refer to the Plan Contract for a complete listing
and additional information.
- Chiropractic, alternative care, massage, acupuncture and naturopathic care
- Chemical dependency, except as noted for alcohol treatment
- Cosmetic surgery.
- Dental care
- Hearing aids/devices, screening and exams
- Home births and all related services
- Certain mental health services
- Physical exams primarily for camps, sports, insurance,
licensing, employment, or other third-party purposes
- Voluntary sterilization or termination of pregnancy
- Temporomandibular joint (TMJ) services
- Treatment for tobacco addiction, including prescription
drugs
- Obesity or weight control treatment, including surgery and prescription drugs
- Services covered by motor vehicle insurance or other liability insurance
- Drugs not listed in our plan formulary
- Drugs not directly related to treatment of a covered illness or injury
- Over-the-counter (OTC) drugs, medications, or vitamins
- Amphetamines and derivatives,
except for narcolepsy or hyperactivity treatment
- Drugs used to treat shift-sleep disorder, drug induced fatigue or general fatigue
- Fluoride for members over the age of 10 years old
- Drugs to stimulate
hair growth
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