PacificSource Medicare Explorer 16 (PPO)
H4754 - 016 - 0
(3.5 / 5)
PacificSource Medicare Explorer 16 (PPO) is a Medicare Advantage Plan by PacificSource Medicare.
This page features plan details for 2022 PacificSource Medicare Explorer 16 (PPO) H4754 – 016 – 0.
IMPORTANT: This page features the 2022 version of this plan. See the 2025 version using the link below:
No 2025 version found. You can use the location links below to find 2025 plans in your area.
Locations
PacificSource Medicare Explorer 16 (PPO) is offered in the following locations.
Plan Overview
PacificSource Medicare Explorer 16 (PPO) offers the following coverage and cost-sharing.
| Insurer: | PacificSource Medicare |
| Health Plan Deductible: | $0 |
| MOOP: | $5,900.00 |
| Drugs Covered: | No |
Ready to sign up for PacificSource Medicare Explorer 16 (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Premium Breakdown
PacificSource Medicare Explorer 16 (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 |
|---|---|---|---|
| $170.10 | $0.00 | $0.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
PacificSource Medicare Explorer 16 (PPO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | Not covered |
| Endodontics: | Not covered |
| Extractions: | In-Network: 30% coinsurance (limits may apply) (authorization required) |
| Extractions: | Out-of-Network: 30% coinsurance (limits may apply) (authorization required) |
| Non-routine services: | Not covered |
| Periodontics: | Not covered |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered |
| Restorative services: | In-Network: 30% coinsurance (limits may apply) (authorization required) |
| Restorative services: | Out-of-Network: 30% coinsurance (limits may apply) (authorization required) |
Dental (preventive)
| Cleaning: | In-Network: $0 copay (limits may apply) |
| Cleaning: | Out-of-Network: $0 copay (limits may apply) |
| Dental x-ray(s): | In-Network: $0 copay (limits may apply) |
| Dental x-ray(s): | Out-of-Network: $0 copay (limits may apply) |
| Fluoride treatment: | Not covered |
| Oral exam: | In-Network: $0 copay (limits may apply) |
| Oral exam: | Out-of-Network: $0 copay (limits may apply) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | In-Network: $0-310 copay (authorization required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 50% coinsurance (authorization required) |
| Diagnostic tests and procedures: | In-Network: $15 copay or 20% coinsurance (authorization required) |
| Diagnostic tests and procedures: | Out-of-Network: 50% coinsurance (authorization required) |
| Lab services: | In-Network: $0-15 copay or 20% coinsurance (authorization required) |
| Lab services: | Out-of-Network: 50% coinsurance (authorization required) |
| Outpatient x-rays: | In-Network: $0-15 copay (authorization required) |
| Outpatient x-rays: | Out-of-Network: 50% coinsurance (authorization required) |
Doctor visits
| Primary: | In-Network: $0-10 copay per visit |
| Primary: | Out-of-Network: 50% coinsurance per visit |
| Specialist: | In-Network: $0-35 copay per visit (authorization required) |
| Specialist: | Out-of-Network: 50% coinsurance per visit (authorization required) |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $40 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | In-Network: $35 copay |
| Foot exams and treatment: | Out-of-Network: 50% coinsurance |
| Routine foot care: | Not covered |
Ground ambulance
| In-Network: $250 copay | |
| Out-of-Network: $250 copay or 20% coinsurance |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | In-Network: $0 copay |
| Fitting/evaluation: | Out-of-Network: $0 copay |
| Hearing aids: | In-Network: $599-999 copay (limits may apply) |
| Hearing aids: | Out-of-Network: $599-999 copay (limits may apply) |
| Hearing exam: | In-Network: $35 copay |
| Hearing exam: | Out-of-Network: 50% coinsurance |
Hospital coverage (inpatient)
| In-Network: $285 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) | |
| Out-of-Network: 50% per stay (authorization required) |
Hospital coverage (outpatient)
| In-Network: $0-285 copay per visit (authorization required) | |
| Out-of-Network: 50% coinsurance per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $10,000 In and Out-of-network $5,900 In-network |
Medical equipment/supplies
| Diabetes supplies: | In-Network: $0 copay (authorization required) |
| Diabetes supplies: | Out-of-Network: 50% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 50% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | In-Network: 0-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 50% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 50% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 50% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | In-Network: $230 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) |
| Inpatient hospital – psychiatric: | Out-of-Network: 50% per stay (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $25 copay |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: 50% coinsurance |
| Outpatient group therapy visit: | In-Network: $25 copay |
| Outpatient group therapy visit: | Out-of-Network: 50% coinsurance |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $25 copay |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: 50% coinsurance |
| Outpatient individual therapy visit: | In-Network: $25 copay |
| Outpatient individual therapy visit: | Out-of-Network: 50% coinsurance |
Optional supplemental benefits
| Yes |
Preventive care
| In-Network: $0 copay | |
| Out-of-Network: 50% coinsurance |
Rehabilitation services
| Occupational therapy visit: | In-Network: $35 copay (authorization required) |
| Occupational therapy visit: | Out-of-Network: 50% coinsurance (authorization required) |
| Physical therapy and speech and language therapy visit: | In-Network: $35 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: 50% coinsurance (authorization required) |
Skilled Nursing Facility
| In-Network: $0 per day for days 1 through 20 $188 per day for days 21 through 100 (authorization required) | |
| Out-of-Network: 50% per stay 50% per day for days 1 through 100 (authorization required) |
Transportation
| Not covered |
Vision
| Contact lenses: | In-Network: $0 copay (limits may apply) |
| Contact lenses: | Out-of-Network: $0 copay (limits may apply) |
| Eyeglass frames: | In-Network: $0 copay (limits may apply) |
| Eyeglass frames: | Out-of-Network: $0 copay (limits may apply) |
| Eyeglass lenses: | In-Network: $0 copay (limits may apply) |
| Eyeglass lenses: | Out-of-Network: $0 copay (limits may apply) |
| Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) |
| Eyeglasses (frames and lenses): | Out-of-Network: $0 copay (limits may apply) |
| Other: | In-Network: $0 copay |
| Other: | Out-of-Network: $35 copay or 50% coinsurance |
| Routine eye exam: | In-Network: $35 copay (limits may apply) |
| Routine eye exam: | Out-of-Network: $35 copay or 50% coinsurance (limits may apply) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
Optional Benefits
Package #1
| Comprehensive dental: | Monthly Premium: | $57.00 |
| Comprehensive dental: | Deductible: | N/A |
Ready to sign up for PacificSource Medicare Explorer 16 (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST