PacificSource Medicare Explorer Rx 4 (PPO)
Available to residents of Lane County, OR for 2026. Contract H4754, plan 004, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Lane County
- Plan website
- Browse the PacificSource Medicare Explorer Rx 4 (PPO) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $157.00 |
|---|---|
| — medical (Part C) part | $68.30 |
| — drug (Part D) part | $88.70? |
| Monthly premium with full Extra Help (LIS) | $146.50?drug (Part D) part $78.20; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $6,700.00? |
| In- and out-of-network out-of-pocket maximum | $8,950.00 |
| Drug deductible | $499.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | PPO? |
| Contract / plan | H4754-004-0 |
| 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 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 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H4754 shares this rating.
Plan health benefits
| Service | In-network | Out-of-network? |
|---|---|---|
| Doctor visits | ||
| Primary care doctor | $0–$15 copay | 50% coinsurance |
| Specialist | $0–$40 copay(authorization required) | 50% coinsurance |
| Other health care professional | $15–$40 copay(authorization required) | 50% coinsurance |
| Additional telehealth services | $0–$40 copay | — |
| Preventive care | ||
| Medicare-covered preventive services | $0 copay | 50% coinsurance |
| Annual physical exam | $0 copay | 50% coinsurance |
| Kidney disease education | 20% coinsurance | 50% coinsurance |
| Glaucoma screening | $0 copay | 50% coinsurance |
| Diabetes self-management training | $0 copay | 50% coinsurance |
| Diagnostic tests, labs and imaging | ||
| Diagnostic tests and procedures | $15 copay; 20% coinsurance(authorization required) | 50% coinsurance |
| Lab services | $0–$15 copay; 20% coinsurance(authorization required) | 50% coinsurance |
| Diagnostic radiology (e.g. MRI, CT) | $0–$400 copay(authorization required) | 50% coinsurance |
| Therapeutic radiology | 20% coinsurance(authorization required) | 50% coinsurance |
| Outpatient x-rays | $0–$15 copay(authorization required) | 50% coinsurance |
| 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 | $275 copay | — |
| Hospital care | ||
| Inpatient hospital stay | $450 per day for days 1–6; $0 per day for days 7–90(authorization required) | 50% coinsurance per stay |
| Outpatient hospital services | $0–$450 copay(authorization required) | 50% coinsurance |
| Outpatient observation | $450 copay | 50% coinsurance |
| Ambulatory surgical center | $0–$450 copay(authorization required) | 50% coinsurance |
| Outpatient blood services | $0 copay | 50% coinsurance |
| Skilled nursing and home health | ||
| Skilled nursing facility | $0 per day for days 1–20; $203 per day for days 21–100(authorization required) | 50% coinsurance per stay; 50% coinsurance for days 1–100 |
| Home health care | $0 copay(authorization required) | 50% coinsurance |
| Kidney dialysis | 20% coinsurance | 50% coinsurance |
| Rehabilitation | ||
| Occupational therapy | $35 copay(authorization required) | 50% coinsurance |
| Physical therapy and speech-language therapy | $35 copay(authorization required) | 50% coinsurance |
| Cardiac rehabilitation | $35 copay | 50% coinsurance |
| Pulmonary rehabilitation | $15 copay | 50% coinsurance |
| Mental health and substance use | ||
| Inpatient psychiatric hospital stay | $330 per day for days 1–5; $0 per day for days 6–90(authorization required) | 50% coinsurance per stay |
| Outpatient mental health, individual session | $30 copay | 50% coinsurance |
| Outpatient mental health, group session | $30 copay | 50% coinsurance |
| Psychiatrist, individual session | $30 copay | 50% coinsurance |
| Psychiatrist, group session | $30 copay | 50% coinsurance |
| Partial hospitalization | $35 copay(authorization required) | 50% coinsurance |
| Intensive outpatient program | $35 copay(authorization required) | 50% coinsurance |
| Outpatient substance use, individual session | $35 copay | 50% coinsurance |
| Outpatient substance use, group session | $35 copay | 50% coinsurance |
| Opioid treatment program | $35 copay | 50% coinsurance |
| Ambulance and transportation | ||
| Ground ambulance | $275 copay(authorization required) | $275 copay |
| Air ambulance | $275 copay(authorization required) | $275 copay |
| Transportation to plan-approved locations | Not covered | — |
| Medical equipment and supplies | ||
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) | 50% coinsurance |
| Prosthetics (e.g. braces, artificial limbs) | 0%–20% coinsurance(authorization required) | 50% coinsurance |
| Medical supplies | 20% coinsurance(authorization required) | 50% coinsurance |
| Diabetes supplies | 20% coinsurance(authorization required) | 50% coinsurance |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) | 50% coinsurance |
| Chiropractic, acupuncture and foot care | ||
| Chiropractic (Medicare-covered) | $15 copay | 50% coinsurance |
| Routine chiropractic care | $25 copay(limits apply) | $25 copay |
| Acupuncture | $25 copay(limits apply) | $25 copay |
| Foot exams and treatment (Medicare-covered) | $40 copay | 50% coinsurance |
| Routine foot care | Not covered | — |
| Dental? | ||
| Medicare-covered dental services | $35 copay(authorization required) | 50% coinsurance |
| Preventive dental plan limit | $500 plan limit every year | — |
| Oral exams | $0 copay | $0 copay |
| Cleanings | $0 copay | $0 copay |
| Fluoride treatment | $0 copay | $0 copay |
| Dental x-rays | $0 copay | $0 copay |
| Other diagnostic dental services | $0 copay | $0 copay |
| Other preventive dental services | $0 copay | $0 copay |
| Restorative services (fillings, crowns) | 50% coinsurance | 50% coinsurance |
| Endodontics (root canals) | 50% coinsurance | 50% coinsurance |
| Periodontics (gum disease) | 50% coinsurance | 50% coinsurance |
| Dentures and other removable prosthodontics | 50% coinsurance | 50% coinsurance |
| Maxillofacial prosthetics | Not covered | — |
| Implants | 50% coinsurance | 50% coinsurance |
| Bridges and other fixed prosthodontics | 50% coinsurance | 50% coinsurance |
| Oral and maxillofacial surgery | 50% coinsurance | 50% coinsurance |
| Orthodontics | Not covered | — |
| Adjunctive general services | 50% coinsurance | 50% coinsurance |
| Vision? | ||
| Eye exam (Medicare-covered) | $0 copay | 50% coinsurance |
| Routine eye exam | $35 copay(limits apply) | $35 copay |
| 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) | $0 copay |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) | $0 copay |
| Eyeglass lenses | $0 copay(limits apply) | $0 copay |
| Eyeglass frames | $0 copay(limits apply) | $0 copay |
| Eyewear upgrades | Not covered | — |
| Hearing? | ||
| Hearing exam (Medicare-covered) | $30 copay | 50% coinsurance |
| Routine hearing exam | $0 copay(limits apply) | $0 copay |
| Hearing aid fitting and evaluation | $0 copay | $0 copay |
| Hearing aids (all types) | $599–$999 copay(limits apply) | $599–$999 copay |
| 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) | $35 copay; 50% coinsurance |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 50% coinsurance |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 50% coinsurance |
| Other extra benefits? | ||
| Over-the-counter (OTC) allowance | $100 allowance every year | — |
| Meals after a hospital stay or for a chronic condition | Not covered | — |
| Fitness benefit | $0 copay | $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 | $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; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $6.00 |
| Tier 3 | 20% |
| Tier 4 | 25% |
| Tier 5 | 27% |
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 | $6.00 | $6.00 | $6.00 | $18.00 | $18.00 | $6.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $6.00 | $6.00 | $6.00 | $18.00 | $18.00 | $6.00 |
| Tier 3: Preferred Brand | 20% | 20% | 15% | 20% | 20% | 15% |
| Tier 4: Non-Preferred Drug | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 5: Specialty Tier | 27% | 27% | 27% | 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 |
Benefits in plain text
PacificSource Medicare Explorer Rx 4 (PPO) (H4754-004-0) is a 2026 PPO Medicare Advantage plan offered by PacificSource Medicare, available to residents of Lane County, OR.
The monthly premium is $157.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $146.50.
Its in-network out-of-pocket maximum is $6,700.00.
The combined in- and out-of-network out-of-pocket maximum is $8,950.00.
The drug deductible is $499.00. 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: $6.00; tier 3: 20%; tier 4: 25%; tier 5: 27%.
CMS gives the plan's contract (H4754) an overall rating of 3 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.