2012 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | PacificSource Medicare Explorer Rx 1 (PPO) | ||||
Location: | Lake, Oregon Click to see other locations | ||||
Plan ID: | H4754 - 001 - 0 Click to see other plans | ||||
Member Services: | 1-888-863-3637 TTY users 1-800-735-2900 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the PacificSource Medicare Explorer Rx 1 (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $142.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $0 | ||||
Annual Rx Initial Coverage Limit (ICL): | $2,930 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,400 | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 5,063 drugs | Browse the PacificSource Medicare Explorer Rx 1 (PPO) Formulary | |||
This plan has 4 drug tiers. See cost-sharing highlights below. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $5.00 | $35.00 | $80.00 | 33% | |
• Number of Drugs per Tier: | 2070 | 843 | 1703 | 447 | |
Plan's Pharmacy Search: | https://medicare.pacificsource.com/Tools/PharmacySearch.aspx | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in (H4754 - 001): | 269 members | ||||
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
• Customer Service Rating: | 3 out of 5 Stars. | ||||
• Member Experience Rating: | Insufficient data to rate this plan. | ||||
• Drug Cost Accuracy Rating: | 4 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
$142 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept 'assignment' from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare 'assignment ' your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare 'limiting charge.' If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare 'limiting charge' does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to 'assignment' and 'limiting charges' that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.gov/physician or www.medicare.gov/supplier. You can also call 1-800 | |||||
$3 400 out-of-pocket limit for Medicare-covered services. | |||||
$5 100 out-of-pocket limit for Medicare-covered services. | |||||
$500 plan coverage limit every year for Non-Medicare Supplemental benefits. Contact the plan for services that apply. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. | |||||
** Extra Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$142 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept 'assignment' from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare 'assignment ' your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare 'limiting charge.' If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare 'limiting charge' does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to 'assignment' and 'limiting charges' that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.gov/physician or www.medicare.gov/supplier. You can also call 1-800 | |||||
$3 400 out-of-pocket limit for Medicare-covered services. | |||||
$5 100 out-of-pocket limit for Medicare-covered services. | |||||
$500 plan coverage limit every year for Non-Medicare Supplemental benefits. Contact the plan for services that apply. | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 5: $175 copay per day | |||||
Days 6 - 90: $0 copay per day | |||||
$0 copay for each additional hospital day. | |||||
$875 out-of-pocket limit every stay. | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
20% of the cost for each hospital stay. | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 5: $175 copay per day | |||||
Days 6 - 90: $0 copay per day | |||||
$875 out-of-pocket limit every stay. | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
20% of the cost for each hospital stay. | |||||
Skilled Nursing Facility (SNF) | |||||
Authorization rules may apply. | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
For SNF stays: | |||||
Days 1 - 20: $0 copay per day | |||||
Days 21 - 100: $50 copay per day | |||||
20% of the cost for each SNF stay. | |||||
For each SNF stay: | |||||
Days 1 - 100: 20% of the cost per SNF day | |||||
Home Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered home health visits | |||||
$0 copay for home health visits | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$15 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$25 copay for each in-area network urgent care Medicare-covered visit | |||||
$30 copay for each specialist visit for Medicare-covered benefits. | |||||
$25 copay for each primary care doctor visit | |||||
$40 copay for each specialist visit | |||||
Chiropractic Services | |||||
$15 copay for each Medicare-covered visit | |||||
$15 copay for each supplemental routine visit | |||||
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. | |||||
$25 copay for chiropractic benefits. | |||||
Podiatry Services | |||||
$30 copay for each Medicare-covered visit | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
20% of the cost for podiatry benefits. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
$30 copay for each Medicare-covered individual therapy visit | |||||
$30 copay for each Medicare-covered group therapy visit | |||||
$30 copay for each Medicare-covered individual therapy visit with a psychiatrist | |||||
$30 copay for each Medicare-covered group therapy visit with a psychiatrist | |||||
$175 copay for Medicare-covered partial hospitalization program services | |||||
20% of the cost for Mental Health benefits with a psychiatrist | |||||
20% of the cost for Mental Health benefits | |||||
20% of the cost for partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
$30 copay for Medicare-covered individual visits | |||||
$30 copay for Medicare-covered group visits | |||||
20% of the cost for outpatient substance abuse benefits. | |||||
Outpatient Services/Surgery | |||||
Authorization rules may apply. | |||||
$175 copay for each Medicare-covered ambulatory surgical center visit | |||||
$175 copay for each Medicare-covered outpatient hospital facility visit | |||||
20% of the cost for outpatient hospital facility benefits. | |||||
20% of the cost for ambulatory surgical center benefits. | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
$50 copay for Medicare-covered ambulance benefits. | |||||
$50 copay for ambulance benefits. | |||||
Emergency Care | |||||
$65 copay for Medicare-covered emergency room visits | |||||
Worldwide coverage. | |||||
If you are admitted to the hospital within 12-hour(s) for the same condition you pay $0 for the emergency room visit. | |||||
Urgently Needed Care | |||||
$25 copay for Medicare-covered urgently-needed-care visits | |||||
Outpatient Rehabilitation Services | |||||
Authorization rules may apply. | |||||
There may be limits on physical therapy occupational therapy and speech and language pathology services If so there may be exceptions to these limits. | |||||
$30 copay for Medicare-covered Occupational Therapy visits | |||||
$30 copay for Medicare-covered Physical and/or Speech and Language Therapy visits | |||||
20% of the cost for Physical and/or Speech and Language Therapy visits | |||||
20% of the cost for Occupational Therapy benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
0% to 20% of the cost for Medicare-covered items | |||||
20% of the cost for durable medical equipment | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
0% to 20% of the cost for Medicare-covered items | |||||
20% of the cost for prosthetic devices. | |||||
Diabetes Programs and Supplies | |||||
$0 copay for Diabetes self-management training | |||||
$0 copay for: | |||||
20% of the cost for Diabetes self-management training | |||||
20% of the cost for Diabetes monitoring supplies | |||||
20% of the cost for Therapeutic shoes or inserts | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
Authorization rules may apply. | |||||
$0 to $10 copay for Medicare-covered lab services | |||||
$0 to $10 copay for Medicare-covered diagnostic procedures and tests | |||||
$10 copay for Medicare-covered X-rays | |||||
$0 to $300 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
$0 copay for Medicare-covered therapeutic radiology services | |||||
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $15 to $30 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $15 to $30 may apply | |||||
20% of the cost for therapeutic radiology services | |||||
20% of the cost for outpatient X-rays | |||||
20% of the cost for diagnostic radiology services | |||||
20% of the cost for diagnostic procedures tests and lab services | |||||
If the doctor provides you services in addition to (Outpatient Diagnostic Procedures/Tests/Lab Services Diagnostic Radiological Services Therapeutic Radiological Services Outpatient X-Rays) separate cost sharing of $25 to $40 may apply | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
$0 copay for: | |||||
20% of the cost for Cardiac Rehabilitation Services | |||||
20% of the cost for Intensive Cardiac Rehabilitation Services | |||||
20% of the cost for Pulmonary Rehabilitation Services | |||||
Preventive Services and Wellness/Education Programs | |||||
$0 copay for all preventive services covered under Original Medicare at zero cost sharing: | |||||
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Please contact plan for details. | |||||
The plan covers the following supplemental education/wellness programs: | |||||
$25 to $40 copay for Medicare-covered preventive services | |||||
$0 copay for supplemental education/wellness programs | |||||
Kidney Disease and Conditions | |||||
$15 copay for renal dialysis | |||||
$0 copay for kidney disease education services | |||||
20% of the cost for kidney disease education services | |||||
$15 copay for renal dialysis | |||||
Outpatient Prescription Drugs | |||||
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |||||
20% of the cost for Part B drugs out-of-network. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://medicare.pacificsource.com/Tools/DrugSearch.aspx on the web. | |||||
Different out-of-pocket costs may apply for people who | |||||
The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). | |||||
Total yearly drug costs are the total drug costs paid by both you and a Part D plan. | |||||
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. | |||||
Some drugs have quantity limits. | |||||
Your provider must get prior authorization from PacificSource Medicare Explorer Rx 1 (PPO) for certain drugs. | |||||
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. | |||||
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. | |||||
If you request a formulary exception for a drug and PacificSource Medicare Explorer Rx 1 (PPO) approves the exception you will pay Tier 2: Preferred Brand Drugs cost sharing for that drug. | |||||
$0 deductible. | |||||
You pay the following until total yearly drug costs reach $2 930: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
After your total yearly drug costs reach $2 930 you receive a discount on brand name drugs and pay 86% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 700. | |||||
After your yearly out-of-pocket drug costs reach $4 700 you pay the greater of: | |||||
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from PacificSource Medicare Explorer Rx 1 (PPO). | |||||
You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 930: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700. You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 700. | |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
After your yearly out-of-pocket drug costs reach $4 700 you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share which is the greater of: | |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
Dental Services | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
$30 copay for Medicare-covered dental benefits | |||||
20% of the cost for comprehensive dental benefits | |||||
Hearing Services | |||||
Hearing aids not covered. | |||||
20% of the cost for hearing exams. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
$0 copay for | |||||
If the doctor provides you services in addition to eye exams separate cost sharing of $15 to $30 may apply | |||||
20% of the cost for eye exams. | |||||
$0 copay for eye wear. | |||||
The plan will pay up to $100 for all of the following services combined: | |||||
$100 plan coverage limit for eye wear every two years. This limit applies to both in-network and out-of-network benefits. | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
Acupuncture | |||||
$15 copay per visit | |||||
$15 copay for acupuncture visits | |||||
The plan will pay up to $500 for all of the following services combined: | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 5: $175 copay per day | |||||
Days 6 - 90: $0 copay per day | |||||
$0 copay for each additional hospital day. | |||||
$875 out-of-pocket limit every stay. | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
20% of the cost for each hospital stay. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$15 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$25 copay for each in-area network urgent care Medicare-covered visit | |||||
$30 copay for each specialist visit for Medicare-covered benefits. | |||||
$25 copay for each primary care doctor visit | |||||
$40 copay for each specialist visit | |||||
Outpatient Services/Surgery | |||||
Authorization rules may apply. | |||||
$175 copay for each Medicare-covered ambulatory surgical center visit | |||||
$175 copay for each Medicare-covered outpatient hospital facility visit | |||||
20% of the cost for outpatient hospital facility benefits. | |||||
20% of the cost for ambulatory surgical center benefits. | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
$50 copay for Medicare-covered ambulance benefits. | |||||
$50 copay for ambulance benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
0% to 20% of the cost for Medicare-covered items | |||||
20% of the cost for durable medical equipment | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
Authorization rules may apply. | |||||
$0 to $10 copay for Medicare-covered lab services | |||||
$0 to $10 copay for Medicare-covered diagnostic procedures and tests | |||||
$10 copay for Medicare-covered X-rays | |||||
$0 to $300 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
$0 copay for Medicare-covered therapeutic radiology services | |||||
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $15 to $30 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $15 to $30 may apply | |||||
20% of the cost for therapeutic radiology services | |||||
20% of the cost for outpatient X-rays | |||||
20% of the cost for diagnostic radiology services | |||||
20% of the cost for diagnostic procedures tests and lab services | |||||
If the doctor provides you services in addition to (Outpatient Diagnostic Procedures/Tests/Lab Services Diagnostic Radiological Services Therapeutic Radiological Services Outpatient X-Rays) separate cost sharing of $25 to $40 may apply | |||||
** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. |