Our office-space closures help ensure community and employee safety
In our effort to slow the spread of COVID-19, PacificSource office locations remain closed. Until further notice, we’re unable to accommodate any walk-in visitors. As always, our Customer Service team is glad to answer your questions by phone or email. Let us know how we can help!
Contact Us
Call for a quote, to enroll, or for more info: 866-282-8814, TTY 711

2021 Essentials 2 (HMO) Plan


This plan's premium is $0.

This Medicare Advantage plan fills in the gaps and covers more services than Medicare alone. This is a Medicare Advantage HMO (Health Maintenance Organization) plan. As a member of this plan, you must use in-network providers to get your medical care and services. Nearly every doctor in the region is accepted so finding a doctor is easy. You also have protection when you travel anywhere in the U.S. and worldwide for emergency and urgent care. To find a provider near you, click on Find a Doctor.

  • View Summary of Benefits

    The Summary of Benefits provides you with a summary of covered benefits. For each benefit, you can see what this plan covers and what Original Medicare covers. This plan offers all the benefits that Original Medicare offers, plus more.

  • Multi-language Interpreter Services

    We have free language interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 888-863-3637. This is a free service.



2021 Essentials 2* (HMO)
$0 per month
Benefit Highlights In-Network
Annual Deductible $0
Referrals Not Required
Annual Out-of-Pocket Maximum
(Medical)
$5,500
Primary Care Provider $10 copay
Specialist $40 copay
Laboratory Lab $15 copay
Genetic testing 20% coinsurance
X-ray $15 copay
Advanced Diagnostics CT Scan & Nuclear $190 copay
MRI & PET Scan $310 copay
Hospitalization $325/day (1-5)
$0/day (6+)
Outpatient Surgery $325 copay
Physical Therapy $35 copay
Skilled Nursing Facility $0/day(1-20)
$184/day (21-100)
Durable Medical Equipment 20% coinsurance
Ambulance (Ground and Air) $300 copay
Emergency Room
Urgent Care
$90 copay
$40 copay
Part B Drugs
(e.g., chemotherapy)
20% coinsurance
Preventive Care In-Network
Bone Mass Measurement (Diagnostic and Screening) $0 copay
Mammograms (Preventive and first Diagnostic exam per calendar year) $0 copay
Prostate Cancer Screenings $0 copay
Cardiovascular Disease Testing $0 copay
Flu and Pneumonia shots $0 copay
Colorectal Cancer Screenings
(Preventive and Diagnostic)
$0 copay
Pap and Pelvic Exams $0 copay
Annual Wellness Visit $0 copay
Diabetes Screening $0 copay
Extra Benefits In-Network
Annual Physical Exams $0 copay
Routine Vision Exams $40 copay
covered every two calendar years
Routine Hearing Exams $0 copay
covered once every calendar year
Eyeglasses and Contacts $200 reimbursement
once every two calendar years
24-Hour NurseLine $0 copay
Silver&Fit© Fitness Program $0 copay
fitness facility & two home fitness kits
Alternative Care $25 copay limit 12 visits/year, combined
(non-Medicare covered acupuncture, naturopathy, and chiropractic)
Chronic Care Management
Transitional Care Management
$0 copay
Over-the-Counter (OTC) $100 benefit limit
covered once every calendar year
Telehealth Services Covered
Assist America® Travel Benefits $0 copay
Meal Delivery Following Hospital or Nursing Facility Stay $0 copay
Rewards & Incentives: earn gift cards for completing preventive care activities Routine physical or annual wellness visit $50 reward
Mammogram $25 reward
Blood Glucose test $15 reward for the first test, $25 reward for the second
Diabetic eye exam $25 reward
Worldwide Coverage for Travelers In-Network
Urgent Care $40 copay
Emergency Room $90 copay
Ambulance (Ground and Air) $300 copay

*You cannot combine Medicare Part D prescription drug coverage from any other company with this plan.


Optional Comprehensive Dental


Comprehensive Dental Plan Benefits1
Premium $50
Annual Deductible $100
Annual Maximum Benefit $1,000
Diagnostic Services
(Preventive Class I)
$0
Restorative & Extraction Services
(Basic Class II)
20%
Endodontics, periodontics, etc.
(Major Class III)
50%
Waiting Period2 Class II: 6 months
Class III: 12 months

We will cover 100% up to our maximum allowable charges for covered services. The maximum allowable is based on the 85th percentile of Usual, Customary, and Reasonable (UCR) charges. If your dentist is out of network and the charges are more than the maximum allowable amount, you will have to pay for the excess charges.

If the optional supplemental benefit includes a waiting period, you may need to complete this period before certain benefits will be paid by our plan. You may receive credit toward the waiting period if you had qualifying dental coverage before enrolling in the Optional Comprehensive Dental plan. To qualify for this credit, there may not have been more than a 63-day gap between you last day of coverage under the previous dental coverage and you first day of coverage under the Optional Comprehensive Dental plan. 


Optional Preventive Dental


Preventive Dental Plan Benefits1
Premium $29
Diagnostic Services
(Preventive Class I)
$0

We will cover 100% up to our maximum allowable charges for covered services. The maximum allowable is based on the 85th percentile of Usual, Customary, and Reasonable (UCR) charges. If your dentist is out of network and the charges are more than the maximum allowable amount, you will have to pay for the excess charges.


$0 Fitness Benefit


Silver and Fit logo Staying active is important to maintaining or improving your health. With the Silver&Fit® Exercise & Healthy Aging Program, you have access to the following at no cost to you:

  • Access to 15,000+ participating fitness centers
  • The Silver&Fit Home Fitness Program
  • Digital workout videos, online classes, fitness tracking, and other tools
  • One-on-one coaching by phone, and more

To learn more and find a fitness center near you, go to www.SilverandFit.com

Silver&Fit is provided by American Specialty Health Fitness, Inc. a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a federally registered trademark of ASH.

TruHearing®


TruHearing logo Good hearing is important to your health. That’s why PacificSource Medicare partners with TruHearing to offer a hearing hardware benefit. This plan includes*:

  • $0 for hearing exam with a TruHearing network provider
  • Purchase up to 2 hearing aids per year ($699 or $999)
    • 48 batteries included with nonrechargable models
    • 45-day money-back guarantee*
    • 3-year warranty
    • 3 follow-up visits for fitting and adjustment (within one year of initial purchase)

* Hearing aid repairs and replacements are subject to provider and manufacturer fees. For questions regarding fees, contact TruHearing customer service.

For information, visit www.TruHearing.com or call 844-255-7141, TTY 711.

Vision Benefits


All our Medicare Advantage plans cover routine vision exams once every two calendar years. You can also receive up to $200 reimbursement for eyeglasses or contact lenses every two calendar years, with the freedom to choose the style you like best. This benefit is not included with Original Medicare, which covers only medical eye care, such as exams that look for signs of eye disease.

Telehealth Benefits


Video- and phone-based care with in-network providers, including primary care, specialists, and mental health, are covered for the same cost as an in-person visit. Applies to most services covered by Medicare. Subject to provider availability and limitations.

Rewards for Healthy Actions


You can earn valuable gift cards — just for completing preventive care services!

We think healthy behaviors should be rewarded. So we're pleased to give you a gift card to your choice of popular retail stores when you complete the preventive screenings shown below.

How it works: Just complete one or more of the $0 copay services below. Once your claim has been processed, you’ll receive a reward certificate in the mail. The certificate allows you to choose a gift card from hundreds of popular retail stores. Options include Amazon, WalMart, Target, Starbucks, CVS, Macy’s, The Home Depot, Best Buy, and more.

Earn one or all of the following rewards per calendar year:

Routine physical or annual wellness visit $50
Mammogram $25
Diabetic A1c (blood glucose test) $15 - First test
$25 - Second test
Diabetic eye exam $25

A few key details

  • There are no copays for these services (no cost to you).
  • This program is available to most PacificSource Medicare Advantage members (not available with PERS plans).
  • No registration is needed.
  • There are no fees associated with gift card activation. Gift cards are valid for 18 months after date of issue.

For more information and a full list of participating retailers, visit Engage.incommincentives.com/pacificsource.

Meals as Medicine


When you’re recovering from a hospital stay, the last thing you need to worry about is cooking. Our plans include 14 home-delivered meals after a recent hospital or nursing facility stay.

  • Two meals per day for seven days
  • Condition-specific menus, such as heart-healthy, diabetic friendly, and low-sodium
  • Vegetarian and kosher options
  • No extra cost to you, and no limit per calendar year

Travel Assistance Program


Assist America logo With PacificSource Medicare, you’re covered for medically necessary emergency and urgent care, and ambulance (ground and air), wherever you travel. You also have access to Assist America®, which can help you obtain services if you become ill or injured while traveling abroad or more than 100 miles from your permanent residence. Services include assistance with:

  • Hospital admission
  • Emergency medical evacuation
  • Evaluation and referrals
  • Medical monitoring and consultation
  • And more

Click here for more information on Assist America

24-Hour NurseLine


Toll-free: 855-834-6150, TTY 711

Have a health-related question? Our 24-Hour NurseLine is staffed around the clock, 7 days a week, and there’s no cost to you. When you have a concern that is not life threatening, you can receive trusted health information and advice from the comfort of your home.

Reimbursement for OTC Aspirin and Calcium


All our Medicare Advantage plans include reimbursement for up to $100 per calendar year for over-the-counter aspirin, calcium, and calcium-vitamin D combinations. Just send us your receipt. Contact Customer Service for more information.

Additional Benefits and Plan Features


The following benefits and services are available to PacificSource Medicare members at no additional cost:

Plan Availability


The 2021 Essentials 2 (HMO) Plan service area includes the following counties in Oregon:

  • Crook
  • Deschutes
  • Grant
  • Hood River
  • Jefferson
  • Klamath: 97731, 97733, 97737, 97739
  • Sherman
  • Wasco
  • Wheeler

Services Not Covered or Limited


The following are some of the items and services that aren’t covered under Original Medicare or by our plans. This is a partial list and does not include all limitations and exclusions. For a detailed list, please see your Evidence of Coverage.

  • Care received in any non-Medicare approved hospital or skilled nursing facility
  • Cosmetic surgery or procedures
  • Custodial care
  • EBT (Electron-Beam Tomography) Scans
  • Elective or voluntary enhancement procedures, services, supplies, and medications
  • Experimental or investigational medical and surgical procedures, equipment, and medications
  • Immunizations for the sole purpose of travel
  • Incontinence supplies
  • Long-term services
  • Orthognathic Surgery for TMJ
  • Orthopedic shoes (some exceptions apply)
  • Private room in a hospital, unless medically necessary
  • Radial keratotomy, LASIK surgery, vision therapy, and other low vision aids and services
  • Routine dental care such as cleanings (unless you have purchased the optional dental coverage), fillings, or dentures
  • Routine lab work, X-rays, or EKG’s done without medical indication except as outlined in the Preventive Services section of the Summary of Benefits
  • Items and services that are specifically excluded by Medicare, with exception of services listed in the benefit chart. To find out more, go to www.Medicare.gov/coverage .

Contact the plan for more information. Limitations, copays, and restrictions may apply. Benefits, premiums, copays and/or coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Enrollment Resources


We understand the importance of choosing a plan that best fits your needs. Start by comparing benefits, copays, coinsurance, monthly premiums, and prescription drug coverage. The links and documents below will help you decide on a plan.

If you want to enroll today, you can follow the easy, step-by-step instructions at our secure online enrollment center. You can also complete the enrollment form below and mail it to us, or simply give us a call and we can enroll you over the phone.

If you prefer to meet with one of our friendly, knowledgeable people, feel free to stop by our office, Monday through Friday from 8:00 a.m. – 5:00 p.m. There is no appointment necessary. We are here to help.

  • View Summary of Benefits

    The Summary of Benefits provides you with a summary of covered benefits. For each benefit, you can see what this plan covers and what Original Medicare covers. This plan offers all the benefits that Original Medicare offers, plus more.

  • Attend a Seminar or Educational Class

    Attend one of our seminars about the plans we offer. Have questions about Medicare? Attend an educational class that is free to the public about Medicare (plan-specific information will not be shared).

  • 2021 HMO Plan Ratings

    The Centers for Medicare & Medicaid (CMS) measures how well Medicare health and drug plans perform on more than 50 different items by rating Medicare Advantage plans on a one to five star scale. Five stars represent the highest quality and value. Plan performance Star Ratings are assessed each year and may change from one year to the next.

  • Multi-Language Interpreter Services

    We have free language interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 888-863-3637. This is a free service.

  • Enrollment Form

    Use this form to enroll today or to change your plan.

Am I eligible to enroll in PacificSource Medicare?


You can enroll in PacificSource Medicare if:

  1. You are enrolled in Medicare Part A and B, and
  2. You do not have End Stage Renal Disease (there are no exclusions for any other health conditions), and
  3. You are a resident of one of the counties in our service area.

When can I enroll?


You can join a PacificSource Medicare plan when:

  1. You are new to Medicare (your first Medicare enrollment opportunity)

    You may enroll three months before the month your Medicare begins, and up to three months after. If you are unsure what date your part A and Part B coverage begins, the lower right hand side of your red, white and blue Medicare card includes this information.

    For Example: If your Medicare begins in July, you can enroll anytime between April 1 and October 1.

  2. You are already on Medicare.

    You can enroll between October 15 – December 7

    You may:

    • Join a PacificSource Medicare plan
    • Change plans
    • Transfer Part D Prescription Drug coverage from one plan or company to another
    • Add or drop Part D Prescription Drug coverage

  3. You qualify for a Special Enrollment Opportunity (exception)

    You may be able to join a PacificSource Medicare plan at other times of the year if:

    • You recently moved into our service area mentioned above
    • You recently lost employer health insurance coverage
    • Your current Medicare Advantage plan is leaving the area
    • Your current plan will no longer be offered
    • You recently became eligible for both Medicaid and Medicare
    • You have been approved for Extra Help from Medicare
    • You recently lost creditable Part D Prescription Drug coverage
    • There may be other exceptions, please contact us for details

Can I enroll today?


Once you decide on the plan that best fits your needs, you can follow the easy, step-by-step instructions at our enrollment center. Our online enrollment is confidential and secure.

If you prefer to meet with one of our friendly, knowledgeable people, please call, email, or stop by our office, Monday through Friday from 8:00 a.m. – 5:00 p.m. There is no appointment necessary. We are here to help.


When will my coverage begin?


After you have enrolled in a PacificSource Medicare plan, generally your coverage will begin the first day of the month after the month we receive your completed enrollment form.

For example:  If we received your enrollment form November 15, your coverage would begin December 1.

In certain instances, you may enroll earlier:

  1. If you are new to Medicare

    You can enroll as early as three months prior to your Medicare coverage beginning.

    For example: If your Medicare coverage begins on July 1, you can enroll as early as April 1.

  2. If you are already enrolled in another plan, you can enroll in a PacificSource Medicare plan during the Annual Enrollment Period:

    For example:

    If you enroll between October 15 – December 7, 2021, your coverage would begin January 1, 2022.

There may be other exceptions, please contact us for details.

After you enroll in a PacificSource Medicare plan we will send your completed enrollment form to the Centers for Medicare & Medicaid Services (CMS) for approval. Once we receive confirmation from CMS, we will send you a confirmation letter.

You will also receive your new member packet and ID card within 10 business days after we receive confirmation from CMS. Your coverage will begin on your effective date. If you have any questions, please call, email, or stop by our office, Monday through Friday from 8:00 a.m. – 5:00 p.m.

Members may enroll in the plan only during specific times of the year. You must have Part A and Part B to enroll in the plan. Contact us for more information.


Contact the plan for more information. Limitations, copays, and restrictions may apply. Benefits, premiums, copays and/or coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

What Is Medicare?


Medicare is a health insurance program for:
  • People age 65 or older
  • People under age 65 with certain disabilities
  • People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

Different Parts of Medicare


Original Medicare Includes Part A and Part B:

Part A - Hospital Insurance:
Part A helps cover inpatient care in hospitals, skilled nursing facilities (not custodial or long-term care), hospice and some home health care. Many people automatically get Part A after you get disability benefits from Social Security. Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working.

Part B - Medical Insurance:
Part B helps cover doctors' services, outpatient hospital care, preventive care, physical and occupational therapists, and some home health care. Most people pay a monthly premium for Part B. You will need to sign up for Part B during your initial enrollment period (the 7-month period that begins 3 months before the month you turn age 65, includes the month you turn age 65, and ends 3 months after the month you turn age 65). If you don’t sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty.

Part C – Medicare Advantage Plans:

Part C is Medicare Advantage plans (like HMO and PPO plans). PacificSource offers Medicare Advantage Plans. Part C is health coverage run by private companies like PacificSource under contract with Medicare. These plans include both Medicare Part A and Part B in the convenience of one plan and fill in some of the gaps in Medicare coverage. Some plans also include Part D Prescription drug coverage and preventive dental in the convenience of one plan. Most people will pay a monthly premium for this coverage. You must continue to pay your Part B premium and must have both Part A and Part B to enroll.

Part D - Prescription Drug Coverage:

Part D is prescription drug coverage run by private companies approved and under contract with Medicare. These plans help lower prescription drug costs and help protect against higher costs in the future. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later. Most people will pay a monthly premium for this coverage.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 877-486-2048, 24 hours a day/7 days a week;
  • The Social Security Office at 800-772-1213 between 7:00 a.m. and 7:00 p.m., Monday through Friday. TTY users should call 800-325-0778; or
  • Your State Medicaid Office.

What You Pay


Below are some of the costs you will pay if you only had original Medicare‡:

Part B (Medical)

  • $135.50 monthly premium*
  • $185 yearly Part B deductible (you must first pay this amount for covered services before Medicare begins paying for your coverage)
  • 20% of the costs for most services including doctor office visits, outpatient surgery, emergency and urgent care

Part A (Hospital)

  • $1,364 deductible per benefit period
  • $0 per day (days 1-60)
  • $341 per day (days 61-90)
  • $682 per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime)
  • You pay all costs beyond lifetime reserve days

Part D (Prescription)

  • Monthly premium: varies by plan and income

‡ The costs above are for 2021, and may change for 2022.

* Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 877-486-2048. You may also call Social Security at 800-772-1213. TTY users should call 800-325-0778.


What Medicare Doesn't Cover


There are some limitations to Original Medicare. In most cases, the following are not covered:

  • You are not covered outside the United States
  • Outpatient prescription drug coverage
  • No annual limit to your total out-of-pocket expenses (example: you will continue paying 20% for most services all year)
  • Not all doctors accept Original Medicare


Medicare Advantage and Medicare Supplement


If you decide you need extra coverage in additional to Original Medicare, you have two options for purchasing additional coverage through Medicare Advantage and Medicare Supplement plans. On both plans, you are still on Medicare. Here are the main differences between these plans:

Medicare Advantage Plan (like PacificSource Medicare plans)
These plans (PacificSource Medicare HMO and PPO plans) fill in the gaps by covering some of the costs Medicare does not cover. We provide more benefits than Medicare alone and Medigap plans. And we provide personal service to make it easy. We offer a variety of plans to meet your needs, including low-priced plans to help save you money. You will also get the convenience of plans that include medical (Part A and Part B) and prescription drug coverage (Part D) all in one plan. You also have the option to add preventive dental to your plan for an additional monthly premium.

Finding a doctor is easier because nearly every doctor in the region is accepted by PacificSource. And, with all our Explorer plans, you have the freedom to see any doctor you want that accepts Medicare wherever you are in the United States. Rest assured you are covered when you travel with worldwide urgent and emergency care.

When you go to the doctor you will need only one ID card: your PacificSource Medicare ID card. The front of the card will show whether you have medical, prescription drug, and/or preventive dental coverage. The doctor will need to send the bill to only one company, your Medicare Advantage plan like PacificSource Medicare. We will pay the bills on behalf of Medicare. Medicare reimburses us for their portion of the costs. Since we deal directly with Medicare, you and your doctor will have less paperwork.

Monthly premiums are the same for all ages. Everyone on one plan will pay the same premium for that year.

For more information on Medicare Advantage plans, or to enroll, please call: 866-282-8814, TTY 711

Medicare Supplement Plan (Medigap)
These plans also fill in the gaps in Medicare coverage. Original Medicare will cover the services under Part A and Part B. The Medigap plan will then cover some of the additional costs Medicare did not cover. If you also wanted Part D coverage, you would need to purchase a Part D prescription drug plan in addition to your Medigap plan.

Not all doctors accept Original Medicare. If your doctor does not accept Original Medicare, then you will either need to find another doctor, pay for the services yourself, or enroll in a plan that has a contract with your doctor. Generally, services outside the United States are not covered.

When you go to the doctor you will need two ID cards: your red, white, and blue Medicare card and your Medigap card. The doctor will need to send the bill to two places: first to Medicare to pay their portion and then to your Medigap plan to pay the plan's portion.

Monthly premiums are based on your age.


How Can I Get More Information About Medicare?


Call 1-800-MEDICARE (1-800-633-4227) or visit www.medicare.gov for more information about Medicare benefits and services including general information regarding medical or Part D benefits. TTY users should call 877-486-2048, 24 hours a day/7 days a week.

Or, come to an ABC’s and D’s of Medicare class sponsored by PacificSource. You can learn more about the often confusing process of the Medicare system, and how to make informed choices about health insurance. You’ll find the information you need to make the right decisions for you and your family. Classes are free and are open to the public. These events are only for educational purposes. No plan-specific benefits or details will be shared. Click here to see our events.


Contact the plan for more information. Limitations, copays, and restrictions may apply. Benefits, premiums, copays and/or coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.