Connect 9000 Bronze

56707OR1380010
Expanded Bronze
EPO

Connect 9000 Bronze is an Expanded Bronze EPO plan by Providence Health Plan.

IMPORTANT: You are viewing the 2023 version of Connect 9000 Bronze 56707OR1380010. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Connect 9000 Bronze is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Connect 9000 Bronze 56707OR1380010.
Insurer: Providence Health Plan
Network Type: EPO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 56707OR1380010

Cost-Sharing Overview

Connect 9000 Bronze offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Connect 9000 Bronze?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Connect 9000 Bronze offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: All Non-PCP Providers
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Connect 9000 Bronze covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency Care and Urgent Care
National Network: No

Additional Benefits and Cost-Sharing

Connect 9000 Bronze includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$60.00 100.00%
Specialist Visit
Covered
$80.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$60.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
No Charge after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
No Charge after deductible 100.00%
Hospice Services
Covered
No Charge 100.00% Respite care provided in a nursing facility subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30 days.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Covered
$25.00 100.00%1 Visit(s) per Year Exam only
Urgent Care Centers or Facilities
Covered
$80.00 $0.00 Copay after deductible
Home Health Care Services
Covered
$0.00 Copay after deductible 100.00%
Emergency Room Services
Covered
No Charge after deductible No Charge after deductible
Emergency Transportation/Ambulance
Covered
No Charge after deductible No Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
No Charge after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
No Charge after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Covered
No Charge after deductible 100.00% Covered when medically necessary due to trauma or disease, or to correct congenital deformities and anomalies.
Skilled Nursing Facility
Covered
No Charge after deductible 100.00%60 Days per Year
Prenatal and Postnatal Care
Covered
No Charge after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$60.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
No Charge after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$60.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
No Charge after deductible 100.00%
Generic Drugs
Covered
$35.00 100.00%30 Days per Month The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $80 max out of pocket for 30 day supply prior to deductible.
Preferred Brand Drugs
Covered
No Charge after deductible 100.00%30 Days per Month The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $80 max out of pocket for 30 day supply prior to deductible.
Non-Preferred Brand Drugs
Covered
No Charge after deductible 100.00%30 Days per Month The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $80 max out of pocket for 30 day supply prior to deductible.
Specialty Drugs
Covered
No Charge after deductible No Charge after deductible30 Days per Month The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $80 max out of pocket for 30 day supply prior to deductible.
Outpatient Rehabilitation Services
Covered
No Charge after deductible 100.00%30 Visit(s) per Year All therapies combined. Additional visits for specified conditions. Visit limit does not apply to treatment of mental health conditions.
Habilitation Services
Covered
No Charge after deductible 100.00%30 Visit(s) per Year All therapies combined. Additional visits for specified conditions. Visit limit does not apply to treatment of mental health conditions.
Chiropractic Care
Covered
$25.00 100.00%20 Visit(s) per Year
Durable Medical Equipment
Covered
No Charge after deductible 100.00%
Hearing Aids
Covered
No Charge after deductible 100.00%2 Item(s) per 3 Years 1 hearing aid per ear every 3 years.
Imaging (CT/PET Scans, MRIs)
Covered
No Charge after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%
Routine Foot Care
Covered
No Charge after deductible 100.00% Covered for patients with diabetes mellitus.
Acupuncture
Covered
$25.00 100.00%12 Visit(s) per Year
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%
Eye Glasses for Children
Covered
No Charge 100.00%
Dental Check-Up for Children
Covered
No Charge 100.00%
Rehabilitative Speech Therapy
Covered
No Charge after deductible 100.00%30 Visit(s) per Year All therapies combined. Additional visits for specified conditions. Visit limit does not apply to treatment of mental health conditions.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
No Charge after deductible 100.00%30 Visit(s) per Year All therapies combined. Additional visits for specified conditions. Visit limit does not apply to treatment of mental health conditions.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
No Charge after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
No Charge after deductible 100.00%
Basic Dental Care – Child
Covered
No Charge after deductible 100.00%
Orthodontia – Child
Covered
No Charge after deductible 100.00% Covered when medically necessary due to trauma or disease, or to correct congenital deformities and anomalies.
Major Dental Care – Child
Covered
No Charge after deductible 100.00%
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Covered
No Charge after deductible 100.00% Covered when medically necessary due to trauma or disease, or to correct congenital deformities and anomalies.
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
No Charge after deductible 100.00%
Accidental Dental
Covered
No Charge after deductible 100.00%
Dialysis
Covered
No Charge after deductible 100.00%
Allergy Testing
Covered
No Charge after deductible 100.00%
Chemotherapy
Covered
No Charge after deductible 100.00%
Radiation
Covered
No Charge after deductible 100.00%
Diabetes Education
Covered
No Charge 100.00%
Prosthetic Devices
Covered
No Charge after deductible 100.00%
Infusion Therapy
Covered
No Charge after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Not Covered
Nutritional Counseling
Covered
No Charge 100.00%
Reconstructive Surgery
Covered
No Charge after deductible 100.00% Covered when medically necessary due to trauma or disease, or to correct congenital deformities and anomalies.
Gender Affirming Care
Covered
Information about gender affirming care can be found in plan documents.
Telehealth – Primary Care Visit
Covered
$10.00 100.00% ExpressCare Virtual No Charge
Telehealth – Specialist
Covered
$80.00 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Connect 9000 Bronze preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Connect 9000 Bronze including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Connect 9000 Bronze?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Table of Contents