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PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) - H3864-024-000

3.5 out of 5 stars* for plan year 2024

$35.00

Monthly Premium

PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by PacificSource Health Plans

Plan ID: H3864-024-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$35.00

Monthly Premium

Idaho Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Idaho Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$35.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$100.00
Out-of-pocket maximum$4,950.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visit
POS (Out-of-Network):

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 50%
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00 to $30.00
Prior Authorization Required for Doctor Specialty Visit
Inpatient hospital careIn-Network:

Acute Hospital Services:
$295.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Urgent care
Urgent Care:
Copayment for Urgent Care $60.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $60.00
Emergency room visit
Emergency Care:
Copayment for Emergency Care $120.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 72 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $120.00
Copayment for Worldwide Emergency Transportation $275.00
Ambulance transportationIn and Out-of-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $275.00

Air Ambulance:
Copayment for Air Ambulance Services $275.00

Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) covers a range of additional benefits. Learn more about PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $20.00
Copayment for Routine Care $25.00
  • Maximum 12 Routine Care every year, combined

POS (Out-of-Network):

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 50%
Chiropractic Services:
Copayment for Non-Medicare Covered Chiropractic Services $25.00
  • Maximum 12 Routine Care every year, combined

Diabetes supplies, training, nutrition therapy and monitoring
POS (Out-of-Network):

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies and Services 50%
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $15.00
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20%
Copayment for Medicare-covered Lab Services $0.00
Coinsurance for Medicare-covered Lab Services 20%
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $310.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

POS (out-of-network)
30%
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00

POS (out-of-network)

Home Health Services
Coinsurance for Medicare-covered Home Health Services: 50%
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$275.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Mental health outpatient care
POS (Out-of-Network):

Outpatient Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 50%
Coinsurance for Medicare Covered Group Sessions 50%
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $275.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $275.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $275.00
Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $35.00
Copayment for Medicare-covered Group Sessions $35.00
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $50.00 every three months

POS (Out-of-Network):

Over-The-Counter (OTC) Items:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $50.00 every three months, must use NationsOTC
Podiatry services
POS (Out-of-Network):

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 50%
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 100

POS (out-of-network)
50% coinsurance

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental care

In-Network:

Medicare Covered Dental Services:

Copayment for Medicare Covered Comprehensive Dental: $35

Non-Medicare Covered Dental
Services:

Copayment for Non-Medicare Covered Preventive Dental: $0

Coinsurance for Non-Medicare Covered Comprehensive Dental: 50%

Maximum Plan Benefit of $1,750 every year, combined in and out-of-network

POS (Out-of-Network):
Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 50%
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00
Coinsurance for Non-Medicare Covered Comprehensive Dental 50%
Maximum Plan Benefit of $1750.00 every year

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Copayment for Eye Exam Other Glaucoma Diabetic Retinopathy $0.00

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear

POS (Out-of-Network):

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 50%
Copayment for Medicare Covered Eyewear $0.00
Non-Medicare Covered Vision Services:

Copayment for Routine Eye Exams $0.00

  • Maximum 1 Routine Eye Exam every year
Copayment for Non-Medicare Covered Eyewear $0.00
Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $35.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $599.00 to $999.00
  • Maximum 2 Hearing Aids every year

POS (Out-of-Network):

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 50%
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $0.00, must use TruHearing
Copayment for Non-Medicare Covered Hearing Aids $599.00 to $999.00, must use TruHearing

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programsIn-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) offers prescription drug coverage, with an annual drug deductible of $100.00 (excludes Tiers 1, 2, and 6)

    Coverage & Cost
    Coverage
    Cost
    Annual drug deductible$100.00 (excludes Tiers 1, 2, and 6)
    Tier 1
    • Preferred retail $0.00
    • Standard retail $8.00
    • Preferred mail order $0.00
    • Standard mail order $8.00
    Tier 2
    • Preferred retail $12.00
    • Standard retail $17.00
    • Preferred mail order $12.00
    • Standard mail order $17.00
    Tier 6
    • Preferred retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $0.00
    Annual drug deductible$100.00 (excludes Tiers 1, 2, and 6)
    Tier 1
    • Preferred retail $0.00
    • Standard retail $16.00
    • Preferred mail order $0.00
    • Standard mail order $16.00
    Tier 2
    • Preferred retail $24.00
    • Standard retail $34.00
    • Preferred mail order $24.00
    • Standard mail order $34.00
    Tier 6
    • Preferred retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $0.00
    Annual drug deductible$100.00 (excludes Tiers 1, 2, and 6)
    Tier 1
    • Preferred retail $0.00
    • Standard retail $24.00
    • Preferred mail order $0.00
    • Standard mail order $24.00
    Tier 2
    • Preferred retail $36.00
    • Standard retail $51.00
    • Preferred mail order $24.00
    • Standard mail order $51.00
    Tier 6
    • Preferred retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $0.00

    When reviewing Idaho Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

    You may be able to find plans in your part of Idaho that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

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    Links to plan documents

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    We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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