Providence Choice Plan benefits

With Providence Choice Plan, you get quality, comprehensive medical coverage and access to providers who are committed to your health care.

• Value Based Drug Formulary (PDF)
• Value Based Drug FAQs (PDF)
• Medical Benefit Drug Prior Authorization List (PDF)
  For all member plan types except Medicare. For pharmacy benefit drug prior authorization information, please refer to your current Formulary.
• Providence Choice Plan member handbook (PDF)
• PEBB frequently asked questions (PDF)

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.

1. Choose a medical home from the provider directory
2. To select a clinic or provider, or to select or change your current medical home, please call 503-574-7500 or 1-800-878-4445 or create a myProvidence account and register for your medical home online.

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Prescription medications

Prior authorization process for nonpreferred prescription drugs
When you and your home clinic physician feel that there are medical reasons for using a nonpreferred 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 plans are designed to direct doctors and patients to effective, quality medications. There also 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 1 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 Providence Health Plan pharmacy benefits. By taking this simple step now, you will be able to avoid any delay in 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

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Bariatric surgery

Bariatric surgery benefits and coverage information
Bariatric surgery is a covered service under your plan if you meet the established criteria. The bariatric surgery guidelines have been designed for patient safety and are based on best practices established by the American Society of Bariatric Surgery. Your medical home clinic physician will work with you to determine if you are a candidate for bariatric surgery and make the appropriate referrals to participating bariatric surgery program. Bariatric surgery requires an extensive evaluation and prior authorization by Providence and is approved for coverage on a case-by-case basis. Bariatric surgery is only covered with participating providers.

Patient eligibility criteria

• Stage 1 - patient consults physician:
  · BMI > 35 with diagnosis of diabetes; or
  · BMI > 40 with any comorbid condition or BMI > 50 with or without comorbid conditions
• Stage 2 - patient completes a six-month work up that includes:
  · Dietary counseling and education; and
  · Medical and psychological evaluation
  · A modest weight loss of > 5 percent over the six months
• Stage 3 - patient completes find preparation for surgery, including:
  · Compliance with stage 2 and approval to proceed
  · Surgery done in a designated, appointed facility

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Providence RN medical advice line

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