PacificSource Medicare MyCare Choice Rx 33 (HMO-POS)
H3864 - 033 - 0
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PacificSource Medicare MyCare Choice Rx 33 (HMO-POS) is a Medicare Advantage (Part C) Plan by PacificSource Medicare.
This page features plan details for 2022 PacificSource Medicare MyCare Choice Rx 33 (HMO-POS) H3864 – 033 – 0 available in Spokane County.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
PacificSource Medicare MyCare Choice Rx 33 (HMO-POS) is offered in the following locations.
Plan Overview
PacificSource Medicare MyCare Choice Rx 33 (HMO-POS) offers the following coverage and cost-sharing.
| Insurer: | PacificSource Medicare |
| Health Plan Deductible: | $0 |
| MOOP: | $4,950.00 |
| Drugs Covered: | Yes |
Ready to sign up for PacificSource Medicare MyCare Choice Rx 33 (HMO-POS) ?
Premium Breakdown
PacificSource Medicare MyCare Choice Rx 33 (HMO-POS) has a monthly premium of $0. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $0.00 | $0.00 | $0.00 | $170.10 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
PacificSource Medicare MyCare Choice Rx 33 (HMO-POS) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Initial Coverage Phase
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
PacificSource Medicare MyCare Choice Rx 33 (HMO-POS) 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 copay |
| Primary: | Out-of-Network: $45 copay or 50% coinsurance per visit |
| Specialist: | In-Network: $0-40 copay per visit (authorization required) |
| Specialist: | Out-of-Network: $45 copay or 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: $40 copay |
| Foot exams and treatment: | Out-of-Network: 50% coinsurance |
| Routine foot care: | Not covered |
Ground ambulance
| In-Network: $300 copay | |
| Out-of-Network: $300 copay |
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: $40 copay |
| Hearing exam: | Out-of-Network: 50% coinsurance |
Hospital coverage (inpatient)
| In-Network: $315 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: $0-390 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)
| $4,950 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: $245 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: $30 copay |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: 50% coinsurance |
| Outpatient group therapy visit: | In-Network: $30 copay |
| Outpatient group therapy visit: | Out-of-Network: 50% coinsurance |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $30 copay |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: 50% coinsurance |
| Outpatient individual therapy visit: | In-Network: $30 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: $40 copay (authorization required) |
| Occupational therapy visit: | Out-of-Network: $45 copay or 50% coinsurance (authorization required) |
| Physical therapy and speech and language therapy visit: | In-Network: $40 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: $45 copay or 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 (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: $40 copay or 50% coinsurance |
| Routine eye exam: | In-Network: $40 copay (limits may apply) |
| Routine eye exam: | Out-of-Network: $40 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 MyCare Choice Rx 33 (HMO-POS) ?