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PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) - H3864-024-000
$35.00
Monthly Premium
PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by PacificSource Health Plans
Plan ID: H3864-024-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$35.00
Monthly Premium
Idaho Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Idaho Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $35.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $100.00 |
| Out-of-pocket maximum | $4,950.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $8,000.00 |
| Primary care doctor visit | POS (Out-of-Network): Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 50% |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 to $30.00 Prior Authorization Required for Doctor Specialty Visit |
| Inpatient hospital care | In-Network: Acute Hospital Services: $295.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 |
| Urgent care | Urgent Care: Copayment for Urgent Care $60.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $60.00 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $120.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 72 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120.00 Copayment for Worldwide Emergency Transportation $275.00 |
| Ambulance transportation | In and Out-of-Network: Ground Ambulance: Copayment for Ground Ambulance Services $275.00 Air Ambulance: Copayment for Air Ambulance Services $275.00 Please see Evidence of Coverage for Prior Authorization rules |
Health Care Services and Medical Supplies
PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) covers a range of additional benefits. Learn more about PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $20.00 Copayment for Routine Care $25.00
POS (Out-of-Network): Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 50% Chiropractic Services: Copayment for Non-Medicare Covered Chiropractic Services $25.00
|
| Diabetes supplies, training, nutrition therapy and monitoring | POS (Out-of-Network): Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies and Services 50% |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $15.00 Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20% Copayment for Medicare-covered Lab Services $0.00 Coinsurance for Medicare-covered Lab Services 20% Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $310.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services POS (out-of-network) 30% |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 POS (out-of-network) Home Health Services Coinsurance for Medicare-covered Home Health Services: 50% |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $275.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 |
| Mental health outpatient care | POS (Out-of-Network): Outpatient Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $275.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $275.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 to $275.00 Prior Authorization Required for Ambulatory Surgical Center Services |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $35.00 Copayment for Medicare-covered Group Sessions $35.00 |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $50.00 every three months POS (Out-of-Network): Over-The-Counter (OTC) Items: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $50.00 every three months, must use NationsOTC |
| Podiatry services | POS (Out-of-Network): Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 50% |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $203.00 per day for days 21 to 100 POS (out-of-network) 50% coinsurance |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental: $35 Non-Medicare Covered Dental Copayment for Non-Medicare Covered Preventive Dental: $0 Coinsurance for Non-Medicare Covered Comprehensive Dental: 50% Maximum Plan Benefit of $1,750 every year, combined in and out-of-network |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear POS (Out-of-Network): Medicare Covered Vision Services: Coinsurance for Medicare Covered Eye Exams 50% Copayment for Medicare Covered Eyewear $0.00 Non-Medicare Covered Vision Services: Copayment for Routine Eye Exams $0.00
Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $35.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $599.00 to $999.00
POS (Out-of-Network): Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 50% Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $0.00, must use TruHearing Copayment for Non-Medicare Covered Hearing Aids $599.00 to $999.00, must use TruHearing |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) offers prescription drug coverage, with an annual drug deductible of $100.00 (excludes Tiers 1, 2, and 6)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $100.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
| Annual drug deductible | $100.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
| Annual drug deductible | $100.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
When reviewing Idaho Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Idaho that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Idaho Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.