PacificSource Medicare Essentials Rx 6 (HMO)
Available to residents of Crook County, OR for 2026. Contract H3864, plan 006, segment 0.
- ✉ Email a copy of the plan benefit details
- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Crook County
- Plan website
- Browse the PacificSource Medicare Essentials Rx 6 (HMO) formulary
Renewed, service area reduced for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $223.00 |
|---|---|
| — medical (Part C) part | $117.10 |
| — drug (Part D) part | $105.90? |
| Monthly premium with full Extra Help (LIS) | $212.50?drug (Part D) part $95.40; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $5,500.00? |
| Drug deductible | $99.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO? |
| Contract / plan | H3864-006-0 |
| Offered by | PacificSource Medicare |
| Parent organization | PacificSource |
| Formulary drugs | 3,742 |
| Formulary exception tier | 5? |
| Pharmacy search | medicare.pacificsource.com/Search/Pharmacy |
| Member services | (888)863-3637TTY 711 |
CMS star ratings
- Overall
- 3.5 out of 5 stars for Overall
- Health plan (Part C)
- 3.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 3.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H3864 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $0–$15 copay(authorization required) |
| Other health care professional | $0–$25 copay(authorization required) |
| Additional telehealth services | $0–$25 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | 20% coinsurance |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $15 copay; 20% coinsurance(authorization required) |
| Lab services | $0–$25 copay; 20% coinsurance(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | $0–$325 copay(authorization required) |
| Therapeutic radiology | 20% coinsurance(authorization required) |
| Outpatient x-rays | $0–$10 copay(authorization required) |
| Emergency and urgent care | |
| Emergency room | $120 copay |
| Urgent care | $50 copay |
| Worldwide emergency coverage | $120 copay |
| Worldwide urgent care | $50 copay |
| Worldwide emergency transportation | $250 copay |
| Hospital care | |
| Inpatient hospital stay | $350 per day for days 1–7; $0 per day for days 8–90(authorization required) |
| Outpatient hospital services | $0–$275 copay(authorization required) |
| Outpatient observation | $275 copay |
| Ambulatory surgical center | $0–$275 copay(authorization required) |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $203 per day for days 21–100(authorization required) |
| Home health care | $0 copay(authorization required) |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $15 copay(authorization required) |
| Physical therapy and speech-language therapy | $15 copay(authorization required) |
| Cardiac rehabilitation | $25 copay |
| Pulmonary rehabilitation | $15 copay |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $275 per day for days 1–5; $0 per day for days 6–90(authorization required) |
| Outpatient mental health, individual session | $20 copay |
| Outpatient mental health, group session | $20 copay |
| Psychiatrist, individual session | $20 copay |
| Psychiatrist, group session | $20 copay |
| Partial hospitalization | $30 copay(authorization required) |
| Intensive outpatient program | $30 copay(authorization required) |
| Outpatient substance use, individual session | $25 copay |
| Outpatient substance use, group session | $25 copay |
| Opioid treatment program | $25 copay |
| Ambulance and transportation | |
| Ground ambulance | $250 copay(authorization required) |
| Air ambulance | $250 copay(authorization required) |
| Transportation to plan-approved locations | Not covered |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 0%–20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | $0 copay(authorization required) |
| Diabetic therapeutic shoes or inserts | $0 copay(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $15 copay |
| Routine chiropractic care | $25 copay(limits apply) |
| Acupuncture | $25 copay(limits apply) |
| Foot exams and treatment (Medicare-covered) | $15 copay |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $25 copay(authorization required) |
| Preventive dental plan limit | $1,250 plan limit every year |
| Oral exams | $0 copay |
| Cleanings | $0 copay |
| Fluoride treatment | $0 copay |
| Dental x-rays | $0 copay |
| Other diagnostic dental services | $0 copay |
| Other preventive dental services | $0 copay |
| Restorative services (fillings, crowns) | 50% coinsurance |
| Endodontics (root canals) | 50% coinsurance |
| Periodontics (gum disease) | 50% coinsurance |
| Dentures and other removable prosthodontics | 50% coinsurance |
| Maxillofacial prosthetics | Not covered |
| Implants | 50% coinsurance |
| Bridges and other fixed prosthodontics | 50% coinsurance |
| Oral and maxillofacial surgery | 50% coinsurance |
| Orthodontics | Not covered |
| Adjunctive general services | 50% coinsurance |
| Vision? | |
| Eye exam (Medicare-covered) | $0 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Eyewear plan limit | $200 plan limit every two years |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $25 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay |
| Hearing aids (all types) | $599–$999 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $25 allowance every three months |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | $0 copay |
| Health education | Not covered |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | Not covered |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | $25 copay |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $12.00 |
| Tier 3 | 24% |
| Tier 4 | 28% |
| Tier 5 | 31% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $12.00 | $12.00 | $12.00 | $36.00 | $36.00 | $12.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $12.00 | $12.00 | $12.00 | $36.00 | $36.00 | $12.00 |
| Tier 3: Preferred Brand | 24% | 24% | 15% | 24% | 24% | 15% |
| Tier 4: Non-Preferred Drug | 28% | 28% | 28% | 28% | 28% | 28% |
| Tier 5: Specialty Tier | 31% | 31% | 31% | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 6 other OR counties
Benefits in plain text
PacificSource Medicare Essentials Rx 6 (HMO) (H3864-006-0) is a 2026 HMO Medicare Advantage plan offered by PacificSource Medicare, available to residents of Crook County, OR.
The monthly premium is $223.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $212.50.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $5,500.00.
The drug deductible is $99.00. Tier 1 and 2 exempt.
The plan's formulary lists 3,742 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $12.00; tier 3: 24%; tier 4: 28%; tier 5: 31%.
CMS gives the plan's contract (H3864) an overall rating of 3.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.