PacificSource Medicare Explorer 6 (PPO)
H4754 - 006 - 0
(3.5 / 5)
PacificSource Medicare Explorer 6 (PPO) is a Medicare Advantage (Part C) Plan by PacificSource Medicare.
This page features plan details for 2024 PacificSource Medicare Explorer 6 (PPO) H4754 – 006 – 0 available in Select Idaho and Montana Counties.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
PacificSource Medicare Explorer 6 (PPO) is offered in the following locations.
Plan Overview
PacificSource Medicare Explorer 6 (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 6 (PPO) ?
Premium Breakdown
PacificSource Medicare Explorer 6 (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 6 (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 | $0-100 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) | $0-310 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 | 50% coinsurance (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 | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Restorative services | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Restorative services | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Endodontics | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Endodontics | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Periodontics | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Periodontics | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Extractions | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Extractions | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | 50% coinsurance (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 6 (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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