PacificSource Medicare Explorer 6 (PPO) – H4754-006-0
This page outlines coverage, cost, and availability for PacificSource Medicare’s H4754-006-0 Medicare Advantage plan for CY2025.
Plan Availability
PacificSource Medicare Explorer 6 (H4754-006-0) is available in the following locations (click to open):
📄 Plan Contact Information
| Website: | PacificSource Medicare Plan Page (opens in new tab) |
|---|---|
| Providers: | PacificSource Medicare Providers Page (opens in new tab) |
| New Member Health Plan Help: | (888)863-3637 |
| New Member TTY: | 711 |
🛡️ Official Medicare Enrollment Resources
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.
Health Plan Costs
💰 Monthly Premium, Deductible, Max Out-of-Pocket & Giveback
Monthly Premium: The total monthly premium is $0.00, including drug coverage. You must also pay your standard Medicare Part B premium.
Health Plan Deductible: Some health plans have a deductible (amount you pay before cost-sharing begins). This plan's deductible is $0.00.
Maximum Out-of-Pocket: All Medicare Advantage plans have an annual maximum out-of-pocket (MOOP) limit. This is the most you will pay for standard health services in a year before that plan begins paying all costs. This plan's MOOP is $4,200.00 for in-network services, excluding the cost of your Part D medications.
Part B Giveback: This plan offers a Part B premium giveback of $0.00.
Health Plan Out-of-Pocket Costs
🩺 Doctor’s Office Visits
- Primary: Not Covered
- Specialist: Not Covered
- NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
🏥 Emergency, Urgent, and Inpatient Hospital Coverage
- Emergency room care: $120 Copay
- Urgent care: $55 Copay
- Ground ambulance: $250 Copay
- Inpatient hospital care: $250.00 per day for days 1 through 5
$0.00 per day for days 6 and beyond - Skilled Nursing Facility: $0.00 per day for days 1 through 20
$203.00 per day for days 21 and beyond
🦶 Foot Care
- Foot Exams and Treatments (Medicare-covered): Not Covered
- Routine Foot Care: Not Covered
💆 Chiropractic Care
- Medicare-covered chiropractic: Not Covered
- Routine chiropractic: Not Covered
🧠 Mental Health Services
- Outpatient individual therapy: Not Covered
- Outpatient group therapy: Not Covered
- Inpatient psychiatric hospital care: $230.00 per day for days 1 through 5
$0.00 per day for days 6 and beyond
🏋️ Rehabilitation Services
- Physical therapy and speech and language therapy: Not Covered
- Occupational therapy: Not Covered
🧰 Medical Equipment and Supplies
- Diabetes supplies: Not Covered
- Durable medical equipment: 20% Coinsurance
Prior Authorization Required - Prosthetics: 20% Coinsurance
🔬 Diagnostics, Lab Services, and Imaging
- Diagnostic radiology services: $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
- Chemotherapy: 20% Coinsurance
- Other Part B drugs (Medicare-covered): 20% Coinsurance
Supplemental Benefits
🦷 Dental Services
- Medicare Covered Preventive Dental: $35 Copay
Prior Authorization Required - Oral exam: $0
- Dental x-rays: $0
- Cleaning: $0
- Periodontics: Not Covered
- Endodontics: Not Covered
- Restorative Services: Not Covered
- Maximum dental benefit
- $1,000.00 (Every year)
👂 Hearing Aids and Services
- Fitting/evaluation: Covered
Limits may apply - Hearing aids: Not Covered
- Hearing exam: Covered
Limits may apply
👓 Vision Services
- Medicare-covered eye exam:
- Routine eye exam: Covered
Limits may apply - Eyewear benefits: None
Prescription Drug 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) and drug plans (Part D) in several major categories using a 5-star rating system. These ratings are designed to help you understand the quality of care and service you can expect if you join PacificSource Medicare Explorer 6.
Frequently Asked Questions
📘 What does Medicare plan code H4754 006 mean?
PacificSource Medicare Explorer 6 is a Medicare Advantage plan by PacificSource Medicare. The code H4754 is the CMS contract ID, whereas 006 is its plan ID.
- Plan Name: PacificSource Medicare Explorer 6
- Plan Type: PPO
- Premium: $0.00/mo + your monthly Part B premium
- Out-of-Pocket Max: $4,200.00 (in-network)
- Drug Coverage: Does not include Medicare Part D prescription drug coverage.
- CMS Star Rating: 3.5 out of 5
- Contract Year: 2025
This information is based on official CMS data and is provided for educational purposes. Always review your plan’s official documents or contact the provider directly before making enrollment decisions.
📋 What type of plan is H4754 006?
This plan is a PPO — specifically, it's an PPO plan with a Medicare Advantage contract that's offered by PacificSource Medicare. It comes with defined provider network rules you should be aware of.
- Plan Marketing Name: PacificSource Medicare Explorer 6
- Network Type: Preferred Provider Organization with in- and out-of-network coverage.
- Referral Requirement: Referrals are generally not required, though some services may be exceptions. Refer to the plan’s coverage tables above.
- Prescription Coverage: Does not include Medicare Part D prescription drug coverage.
Plan types like HMOs and PPOs determine whether you can go out-of-network or need referrals to see specialists.
📦 What benefits are included in H4754 006?
This plan covers all Medicare Part A and Part B services. Depending on the plan, it may also include valuable extras like dental, vision, and hearing benefits.
- Medical Services: Hospital, doctor visits, preventive care
- Prescription Drugs: Not Included
- Dental: No — this plan does not include dental benefits.
- Vision: Yes — vision benefits are included. Review the vision section above for copay and limit details.
- Hearing: Yes — hearing benefits are included. See the coverage details above to learn what services are covered.
Benefit availability may vary by location and plan version. Confirm specific details in your plan's Evidence of Coverage (EOC).