PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) H3864-014-0 Plan Details
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*CMS rated this PacificSource Medicare plan (H3864-014-0) 3.5 (Above Average) out of 5 stars.
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) is a Medicare Advantage plan with Part D benefits. The 2025 Annual Enrollment period starts October 15. Plan benefits begi
PacificSource Medicare Essentials Choice Rx 14 Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | H3864-014-0 |
| Plan Type: | HMO-POS |
| Plan Year: | 2025 |
| Premium: | $93.00/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 5,950.00 /yr |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Enhanced, $199.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | See List |
| Insured By: | PacificSource Medicare |
| Summary of Benefits |
|---|
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 H3864-014-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | $10 Copay |
| Specialist: | $35 Copay Prior Authorization Required |
Emergency, Urgent, and Inpatient Hospital Coverage
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $120 Copay |
| Urgent care: | $55 Copay |
| Ground ambulance: | $300 Copay |
| Inpatient hospital care: | $375.00 per day for days 1 through 7 $0.00 per day for days 8 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
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $35 Copay |
| Routine Foot Care: | Not Covered |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $20 Copay |
| Routine chiropractic: | Not Covered |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $30 Copay |
| Outpatient group therapy: | $30 Copay |
| Inpatient psychiatric hospital care: | $275.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
Rehabilitation Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $35 Copay |
| Occupational therapy: | $35 Copay |
Medical Equipment and Supplies
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | Not Covered |
| Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
| Prosthetics: | 20% Coinsurance |
Diagnostics, Lab Services, and Imaging
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $340 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
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
Dental Services
| Service | Member Cost (in-network) |
|---|---|
| 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: | $1,500.00 (Every year) |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Not Covered |
| Hearing exam | Covered Limits may apply |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam (in-network) | |
| Routine eye exam (in-network) | Covered Limits may apply |
| Eyewear benefits | None |
Feel free to download our PacificSource Medicare Essentials Choice Rx 14 Summary of Benefits information.
Prescription Drug Plan Costs & Benefits
PacificSource Medicare Essentials Choice Rx 14 includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans offer greater coverage than basic plans, typically providing lower cost-sharing, broader drug coverage, and additional benefits, such as covering drugs not included in the standard formulary. These plans usually have higher premiums due to the extra coverage and flexibility they provide, but they cover a larger percentage of overall drug costs.
As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. LIS, also known as Extra Help, is a Social Security program that helps people with limited income and resources lower or cut Part D costs.
The following table outlines the premium details of this prescription drug plan.
| Basic Part D Premium: | $11.70 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $11.70 |
| Low Income Premium Subsidy: | $26.15 |
| Low Income Premium Subsidy CMS Pays: | $11.70 |
| Low Income Subsidy Premium: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $199.00. You must pay this amount at the pharmacy before PacificSource Medicare begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, PacificSource Medicare Essentials Choice Rx 14 has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order | Out of Network |
|---|---|---|---|
| Preferred Generic | $0.00 | $8.00 | $8.00 |
| Generic* | $12.00 | $17.00 | $17.00 |
| Preferred Brand* | $47.00 | $47.00 | $47.00 |
| Non-Preferred Drug | 31.00% | 33.00% | 33.00% |
| Specialty Tier | 30.00% | 30.00% | 30.00% |
| *The Part D deductible does not apply. | |||
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 Essentials Choice Rx 14 .
| CMS Measure | Star Rating |
|---|---|
| 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 |
Plan Availability
PacificSource Medicare Essentials Choice Rx 14 (H3864-014-0) is available in the following locations (click to open):
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
- H3864-027-0: PacificSource Medicare Essentials Rx 27 ()
- H3864-040-0: PacificSource Medicare MyCare Rx 40 ()
- H3864-034-0: PacificSource Medicare MyCare Choice Rx 34 ()
- H3864-006-0: PacificSource Medicare Essentials Rx 6 ()
- H3864-029-0: PacificSource Medicare MyCare Choice Rx 29 ()
- H3864-014-0: PacificSource Medicare Essentials Choice Rx 14 ()
- H3864-024-0: PacificSource Medicare MyCare Choice Rx 24 ()
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
| Website: | PacificSource Medicare Plan Page |
|---|---|
| Providers: | PacificSource Medicare Providers Page |
| Formulary: | PacificSource Medicare Formulary Page |
| Pharmacy: | PacificSource Medicare Pharmacy Page |
| New Member Health Plan Help: | (888)863-3637 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (888)863-3637 |
| New Member Part D 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.