PacificSource Medicare Explorer Rx 17 (PPO) 2024 Benefit Details for Plan H4754-017-0 by PacificSource Medicare
PacificSource Medicare Explorer Rx 17 is a 2024 PPO Medicare Advantage plan {with_without_pdp} prescription drug plan benefits (Part D).
This PacificSource Medicare option offers the same basic benefits as Original Medicare, but out-of-pocket costs are different. It may also include additional, valuable benefits not covered by Part A or Part B.
Plan Basics | |
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Plan ID: | H4754 017 0 |
Plan Type: | Local PPO |
Plan Year: | 2024 |
Premium: | $23.00/mo Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | $5,900/yr |
Part B Reduction: | $0.00/mo |
Drug Plan Benefit: | Enhanced, $225.00 deductible |
Rx Gap Coverage: | Yes |
Supplemental Benefits: | Vision, Hearing |
Availability: | See List |
Insured By: | PacificSource Medicare |
Summary of Benefits |
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Health Plan Cost Sharing
This PacificSource Medicare Medicare Advantage plan has cost-sharing. These are costs you must pay out-of-pocket when you use approved health services.
NOTE: Most preventive services are covered 100% by the plan as a Part B benefit.
The following table summarizes the most common out-of-pocket costs you will incur if you join this plan unless you go out-of-network:
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $0 |
Specialist: | $35 Copay Authorization Required |
Wellness programs (e.g., fitness, nursing hotline): | None |
Preventive care: | $0 |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $35 Copay |
Routine foot care: | Not Covered |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $20 Copay |
Routine chiropractic care: | Not Covered |
Emergency Care / Urgent Care | |
Emergency room care: | $120 Copay |
Urgent care: | $60 Copay |
Ground ambulance: | $300 Copay |
Inpatient hospital coverage: | $350.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient hospital coverage: | $350 Copay Authorization Required |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $196.00 per day for days 21 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $25 Copay |
Outpatient group therapy visit with a psychiatrist: | $25 Copay |
Inpatient hospital - psychiatric: | $330.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient group therapy visit: | $25 Copay |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $35 Copay |
Occupational therapy visit: | $35 Copay |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | $0 |
Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance 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 Authorization Required |
Lab services: | 20% Coinsurance Authorization Required |
Outpatient x-rays: | $15 Copay Authorization Required |
Diagnostic tests and procedures: | 20% Coinsurance 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 Rx 17 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) | Covered Limits may apply |
Hearing exam (In-Network) | Covered Limits may apply |
Vision | Maximum vision benefit: | $200.00 Every two years |
Eyeglasses (frames and lenses) (In-Network) | Covered Limits may apply |
Routine eye exam (In-Network) | $35 Copay |
Contact lenses (In-Network) | Covered Limits may apply |
Additional Benefits
None specified.
Prescription Drug Plan Costs & Benefits
PacificSource Medicare Explorer Rx 17 includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans have a higher actuarial value than basic plans. Actuarial value simply refers to the percentage of cost that's covered by the plan.
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 prescription drug plan premium details of this plan.
Basic Part D Premium: | $23.00 |
Supplemental Part D Premium: | $0.00 |
Total Part D Premium: | $23.00 |
Part D Premium with Full LIS Assistance: | $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 $225.00. This is the amount you must pay at the pharmacy before PacificSource Medicare begins paying its share.
NOTE: The deductible does not apply to one or more drug tiers in this plan (see "Prescription Drug Plan Out-of-Pocket Costs" below).
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, PacificSource Medicare Explorer Rx 17 has out-of-pocket costs that you must pay when you pick up your prescriptions.
Drug Tier | Preferred | Standard |
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1 (Preferred Generic) | $3.00 copay (deductible does not apply) | $8.00 copay (deductible does not apply) |
2 (Generic) | $12.00 copay | $17.00 copay |
3 (Preferred Brand) | $42.00 copay | $47.00 copay |
4 (Non-Preferred Drug) | 31% | 32% |
5 (Specialty Tier) | 29% | 29% |
6 (Select Care Drugs) | $0.00 copay | $0.00 copay |
CMS 5-Star Rating Marks
The following table shows the quality ratings for this PacificSource Medicare plan. Each year CMS rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories based on a 5-star rating system. Here are the most recent ratings for PacificSource Medicare Explorer Rx 17.
CMS Measure | Star Rating |
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2024 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 |
Most Medicare Advantage PPO plans get average marks, including this one. PacificSource Medicare Explorer Rx 17 does an average job keeping its members healthy through preventive health measures, including screenings, tests, and vaccines. When it comes to helping members manage their chronic health conditions, this plan does an average job.
Medicare beneficiaries enrolled in this PacificSource Medicare plan enjoy a good member experience. Complaints and changes in plan performance are one way we can measure quality, and this plan scores good at both. Not the best or the worst when it comes to customer service, this health plan's customer service is average.
PacificSource Medicare Explorer Rx 17 offers some vision and hearing benefits, but not dental.
With an added premium of $23.00 dollars per month, prospective members are advised to carefully weigh the value of the plan's additional benefits. With a maximum out-of-pocket limit of $5,900 per year, this plan could be costly if you have chronic health conditions. In the event of a 5-day hospital stay, costs will likely be higher than Original Medicare. This health plan does not have an annual deductible, making health care a little easier to budget.
Plan Availability
PacificSource Medicare Explorer Rx 17 (H4754-017-0) is available in the following locations (click to open):
Additional Medicare Advantage Plan Options
The Medicare Advantage program offers a myriad of options, including these plans:
- H4754-017-0: PacificSource Medicare Explorer Rx 17 (PPO)
- H4754-012-0: PacificSource Medicare Explorer 12 (PPO)
- H4754-004-0: PacificSource Medicare Explorer Rx 4 (PPO)
- H4754-011-0: PacificSource Medicare Explorer Rx 11 (PPO)
- H4754-006-0: PacificSource Medicare Explorer 6 (PPO)
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: | (800)735-2900 |
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 Advantage program on www.medicare.gov.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna Healthcare, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, UnitedHealthcare(R), and Wellcare.
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 Handbook", 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
About This H4754-017-0 Plan Detail Page
The data on this PacificSource Medicare Explorer Rx 17 plan detail page is derived from the 2024 Landscape Source Files, Plan Benefit Package, and Medicare Part C and Part D Performance Data published by CMS.
The author interprets these files, and their associated data dictionary, with great care, making every attempt to communicate the data submitted by PacificSource Medicare to CMS as clearly and accurately as possible. Given the complexity of the data, the author recommends that all potential enrollees request an official Summary of Benefits from PacificSource Medicare, at (888)863-3637, prior to enrollment.