PacificSource Medicare Explorer 6 (PPO) Plan Details for Bonner County, ID
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*CMS rated this PacificSource Medicare plan (H4754-006-0) 3.5 (Above Average) out of 5 stars.
PacificSource Medicare Explorer 6 (PPO) is a Medicare Advantage plan with Part D benefits. The 2025 Annual Enrollment period starts October 15. Plan benefits begin January 1.
See more Medicare Advantage Plans in Bonner County, Idaho.
PacificSource Medicare Explorer 6 Basic Details
Plan Basics | |
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Plan ID: | H4754-006-0 |
Plan Type: | PPO |
Plan Year: | 2025 |
Premium: | $0.00/mo Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | 4,200.00 /yr |
Part B Reduction: | $0.00/mo |
Drug Plan Benefit: | Not Included |
Supplemental Benefits: | Vision, Hearing |
Availability: | Bonner County, ID |
Insured By: | PacificSource Medicare |
Summary of Benefits |
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PacificSource Medicare Out-of-Pocket Costs
This PacificSource Medicare Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H4754-006-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $0 |
Specialist: | $0 |
Preventive care: | $0 |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $0 |
Routine foot care: | Not Covered |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $0 |
Routine chiropractic care: | Not Covered |
Emergency Care / Urgent Care | |
Emergency room care: | $120 Copay |
Urgent care: | $55 Copay |
Ground ambulance: | $250 Copay |
Inpatient hospital coverage: | $250.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient hospital coverage: | $250 Copay Prior Authorization Required |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $203.00 per day for days 21 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $0 |
Outpatient group therapy visit with a psychiatrist: | $0 |
Inpatient hospital - psychiatric: | $230.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient group therapy visit: | $0 |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $0 |
Occupational therapy visit: | $0 |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | $0 |
Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Prior Authorization Required |
Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
Diagnostic radiology services (e.g., MRI): | $310 Copay Prior Authorization Required |
Lab services: | 20% Coinsurance Prior Authorization Required |
Outpatient x-rays: | $15 Copay Prior Authorization Required |
Diagnostic tests and procedures: | 20% Coinsurance Prior Authorization Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our PacificSource Medicare Explorer 6 Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits PacificSource Medicare includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | |
Oral exam (In-Network) | Not Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Not Covered |
Cleaning (In-Network) | Not Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Not Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Not Covered |
Extractions (In-Network) | Not Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | Covered Limits may apply |
Hearing aids (In-Network) | Not Covered |
Hearing exam (In-Network) | Covered Limits may apply |
Vision | Maximum vision benefit: | $2.00 Every three years |
Eyeglasses (frames and lenses) (In-Network) | Not Covered |
Routine eye exam (In-Network) | Covered Limits may apply |
Contact lenses (In-Network) | Not Covered |
Prescription Drug Plan Costs & Benefits
This plan does not include a Medicare Part D plan for prescriptions.
CMS 5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories using a 5-star rating system. Here are the most recent CMS ratings for PacificSource Medicare Explorer 6 .
CMS Measure | Star Rating |
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2025 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | |
Managing Chronic (Long Term) Conditions | |
Member Experience with Health Plan | |
Complaints and Changes in Plans Performance | |
Health Plan Customer Service | |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | |
Member Experience with the Drug Plan | |
Drug Safety and Accuracy of Drug Pricing |
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
- PacificSource Medicare Explorer Rx 4
- PacificSource Medicare Explorer Rx 18
- PacificSource Medicare Explorer 6
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact PacificSource Medicare
Plan Website: | http://www.Medicare.PacificSource.com |
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Formulary Information: | https://medicare.pacificsource.com/Search/Pharmacy |
Pharmacy Information: | PacificSource Medicare Pharmacy Page |
Prospective Members: | (888)863-3637 |
TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- PacificSource Medicare, http://www.Medicare.PacificSource.com, Last Accessed February 20, 2024
- Medicare.gov, "Your health plan options", Last Accessed February 20, 2024
- Medicare.gov, "How Original Medicare Works", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.