PacificSource Medicare Explorer 12 (PPO)
H4754 - 012 - 0
(3.5 / 5)
PacificSource Medicare Explorer 12 (PPO) is a Medicare Advantage (Part C) Plan by PacificSource Medicare.
This page features plan details for 2024 PacificSource Medicare Explorer 12 (PPO) H4754 – 012 – 0 available in Select Idaho and Washington Counties.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
PacificSource Medicare Explorer 12 (PPO) is offered in the following locations.
Plan Overview
PacificSource Medicare Explorer 12 (PPO) offers the following coverage and cost-sharing.
| Insurer: | PacificSource Medicare |
| Health Plan Deductible: | $0.00 |
| MOOP: | $8,950 In and Out-of-network $3,950 In-network |
| Drugs Covered: | No |
Ready to sign up for PacificSource Medicare Explorer 12 (PPO) ?
Premium Breakdown
PacificSource Medicare Explorer 12 (PPO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $174.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
PacificSource Medicare Explorer 12 (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $8,950 In and Out-of-network $3,950 In-network |
| No |
| In-network | No |
| In-network | $0-50 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | 35% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | 35% coinsurance per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Specialist | 35% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | 35% coinsurance (Authorization is not required.) (Referral is not required.) |
| Emergency | $120 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $60 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $15 copay or 20% coinsurance (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | 35% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Lab services | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | 35% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $0-200 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | 35% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $0-15 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | 35% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | 35% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $599-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $599-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | 35% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Other | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Other | 35% coinsurance (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | 35% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | 35% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network | $250 copay (Not applicable.) (Not applicable.) |
| out-of-network | $250 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | 35% coinsurance (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 35% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 35% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | 35% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | $35 copay or 35% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | $35 copay or 35% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | $35 copay or 35% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $250 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is not required.) (Referral is not required.) |
| out-of-network | 35% per stay (Authorization is not required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $230 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is not required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | 35% per stay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | 35% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | 35% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | 35% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | 35% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is not required.) (Referral is not required.) |
| out-of-network | 35% per stay 35% per day for days 1 through 100 (Authorization is not required.) (Referral is not required.) |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $57.00 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $57.00 |
| Comprehensive dental: | Deductible: | N/A |
Ready to sign up for PacificSource Medicare Explorer 12 (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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