My Benefits

With Providence Choice Plan, you get quality, comprehensive medical coverage, and the power of choice.

More Benefits

Choose a Medical Home
Prescription Medications
Bariatric Surgery
Providence RN Medical Advice Line
Member Extra Values

First Step: Choose a Medical Home

• When you enroll with Providence Choice Plan, you will need to select a "medical home clinic" for your primary health care for you and each of your family members. Medical home clinics include all Providence Medical Group Clinics and are available throughout the greater Portland area.

• Choose a Medical Home from the provider directory

• To select a clinic or provider (medical home), or to change your current medical home, please call 503-574-7500 or 1-800-878-4445 or create a My Providence account and register your medical home online.

Prescription Medications

• Prior authorization process for non-preferred prescription drugs

When you and your home clinic physician feel that there are medical reasons for using a non-preferred brand-name drug, your physician will work to get approval to have the drug covered at the preferred-brand rate. This is a simple process and will be handled by your home clinic. If you see an out-of-network provider, you or the provider will need to contact the plan and arrange for approval for preferred-brand coverage.

Our pharmacy benefits plans are designed to direct doctors and patients to effective, quality medications that also provide value. There may be effective medication options that are less expensive, such as over-the-counter or generic medication options. Talk to your physician about every medication you take and what alternatives there are for you. Less than one percent of our prescription claims require a prior authorization.

If your medication requires prior authorization, we recommend that you contact your physician. Ask him or her to work with us to get your current medication prior authorized or to change your prescription to an effective alternative medication covered by your PHP pharmacy benefits. By taking this simple step now, you will be able to avoid any delay in the process of having your prescription medication refilled.

The average time for prior authorization review is less than 24 hours at Providence Health Plan once all of the necessary information is available.

More Pharmacy Resources

Bariatric Surgery

• Bariatric surgery benefits and coverage information

Bariatric surgery is a covered benefit under your plan if you meet the established criteria. The bariatric surgery guidelines have been designed to limit mortality and morbidity and are based on those of local health plans and the American Society of Bariatric Surgery. Your medical home clinic physician will work with you to establish if you are a candidate for bariatric surgery and make the appropriate referrals to the Plan’s participating bariatric surgery program. Bariatric surgery is approved for coverage on a case-by-case basis, requires an extensive evaluation and prior authorization by Providence. Bariatric surgery is only covered on your In-Network benefit.

• Patient Eligibility Criteria

Stage 1 - patient consults physician:
· BMI > 35 with diagnosis of diabetes; or
· BMI > 40 with any co-morbid condition or BMI > 50 with or without co-morbid conditions

Stage 2 - patient completes a 6-month work up that includes:
· Dietary counseling and education, and
· Medical and psychological evaluation
· A modest weight loss of > 5 % over the 6 months

Stage 3 - patient completes the final stage includes:
· Compliance with Stage 2 and approval to proceed
· Surgery done in a designated, appointed facility

Providence RN Medical Advice Line

• Free 24-hour medical advice line: 503-574-6520 or 1-800-700-0481

Providence RN is a free medical advice line for Providence Choice Plan members. You can call day or night, seven days a week, to speak with a registered nurse. Our nurses can answer many of your questions, and help you determine when you should seek care from your physician or provider.

Member Extra Values

• Access programs and services that offer discounts to our members including:

· A free 24-hour telephone medical advice line.
· Discounts on recreational and cultural activities including events, fitness clubs and more.
· Discounts on eye examinations, laser vision correction and contact lenses.
· Discounts on acupuncture, chiropractic care, massage therapy and dietitian services.
· Mail-order pharmacy resources.
· Discounts on hearing aids for you, your parents and grandparents.
· Discounts on pregnancy, parenting, fitness, smoking cessation, weight management classes.

More Extra Values

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