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Call for a quote, to enroll, or for more info: 866-282-8814, TTY: 711. We accept all relay calls.

2024 Explorer Rx 4 (PPO) Plan

This plan's premium is $109

This is a PPO Rx plan, which means you are covered for healthcare providers both in our network and outside it. You'll usually pay less when you see in-network providers, but you're free to see any Medicare-participating doctor, anywhere in the country.

You're also covered for urgent and emergency care worldwide, regardless of provider, at the in-network level.

You can find thousands of in-network doctors and facilities in our Provider Directory, including many of the best-known names in the region.

This plan also includes prescription drug coverage (Medicare Part D). You can learn about costs for covered medications with our Drug Search tool, and find nearby pharmacies with our Pharmacy Search.

  • View Summary of Benefits, updated 9/29/2023

    This Medicare Advantage plan includes all the benefits of Original Medicare, plus many more. The Summary of Benefits details what's covered by each plan.

  • Multi-Language Interpreter Services, updated 10/4/2023

    You can get an interpreter to answer any questions about our health or drug plans. To get an interpreter, call us at 888-863-3637. This is a free service.



2024 Explorer Rx 4 (PPO)
$109 per month
Benefit Highlights In-Network Out-of-Network
Annual Medical Deductible $0 $0
Referrals No Referrals Required No Referrals Required
Annual Out-of-Pocket Maximum
(Medical)		 $5,500 $8,950
Primary Care Provider $10 copay 50% coinsurance
Specialist $35 copay 50% coinsurance
Laboratory Lab $15 copay
Genetic testing 20% coinsurance		 50% coinsurance
X-ray $15 copay 50% coinsurance
Advanced Diagnostics CT Scan & Nuclear $225 copay
MRI & PET Scan $310 copay		 50% coinsurance
Hospitalization $360/day (1-5)
$0/day (6+)		 50% coinsurance
Outpatient Surgery $360 copay 50% coinsurance
Physical Therapy $35 copay 50% coinsurance
Skilled Nursing Facility $0/day(1-20)
$203/day (21-100)		 50% coinsurance
Durable Medical Equipment 20% coinsurance 50% coinsurance
Ambulance (Ground and Air) $250 copay $250 copay
Emergency Room
Urgent Care		 $120 copay
$60 copay 		$120 copay
$60 copay
Part B Drugs
(e.g., chemotherapy)		 0% - 20% coinsurance
Insulin: $35 max		 50% coinsurance
Insulin: $35 max
Preventive Care In-Network Out-of-Network
Bone Mass Measurement (Diagnostic and Screening) $0 copay 50% coinsurance
Mammograms (Preventive and first Diagnostic exam per calendar year) $0 copay 50% coinsurance
Prostate Cancer Screenings $0 copay 50% coinsurance
Cardiovascular Disease Testing $0 copay 50% coinsurance
Flu and Pneumonia shots $0 copay 50% coinsurance
Colorectal Cancer Screenings
(Preventive and Diagnostic)		 $0 copay 50% coinsurance
Pap and Pelvic Exams $0 copay 50% coinsurance
Annual Wellness Visit $0 copay 50% coinsurance
Diabetes Screening $0 copay 50% coinsurance
Extra Benefits In-Network Out-of-Network
Preventive Dental $0 copay
$500 maximum benefit limit		 $0 copay
$500 maximum benefit limit
Comprehensive Dental 50% coinsurance
$500 maximum benefit limit combined with Preventive Dental		 50% coinsurance
$500 maximum benefit limit combined with Preventive Dental
Annual Physical Exams $0 copay 50% coinsurance
Routine Vision Exams $35 copay
covered once every two calendar years		 $35 copay
covered once every two calendar years
Routine Hearing Exams $0 copay
covered once every calendar year		 Not Covered
Eyeglasses and Contacts $200 reimbursement
once every two calendar years		 $200 reimbursement
once every two calendar years
Silver&Fit© Fitness Program $0 copay
fitness facility & home fitness kit		 Not Covered
Alternative Care $25 copay limit 12 visits/year, combined
(non-Medicare covered acupuncture, naturopathy, and chiropractic) 		$25 copay limit 12 visits/year, combined
(non-Medicare covered acupuncture, naturopathy, and chiropractic)
Over-the-Counter (OTC) $100 reimbursement for select drugs
covered once every calendar year		 $100 reimbursement for select drugs
covered once every calendar year
Telehealth Services Covered Not Covered
Assist America® Travel Benefits $0 copay Not Covered
Meal Delivery Following Hospital or Nursing Facility Stay $0 copay Not Covered
Rewards & Incentives: earn gift cards for completing preventive care activities Included
Up to $170 in rewards		 Not Covered
Worldwide Coverage for Travelers In-Network Out-of-Network
Urgent Care $60 copay $60 copay
Emergency Room $120 copay $120 copay
Ambulance (Ground and Air) $250 copay $250 copay
Part D Prescription Drug Benefits Preferred Pharmacies Standard Pharmacies
STAGE ONE
Deductible

$0

STAGE TWO
Tier 1
Preferred Generic

$3 copay 30-day supply1,2

$8 copay 30-day supply1,2
Tier 2
Generic

$12 copay 30-day supply1,2

$17 copay 30-day supply1,2
Tier 3
Preferred Brand

$42 copay 30-day supply1,2
Insulin: $35 max1,2

$47 copay 30-day supply1,2
Insulin: $35 max1,2
Tier 4
Non-Preferred Drug

31% coinsurance

33% coinsurance
Tier 5
Specialty

33% coinsurance3
Insulin: $35 max1,2
Tier 6
Select Care Drugs

$0 copay 30-day supply
STAGE THREE What you pay after total drug costs4 reach $5,030
Most Generic

25% coinsurance
Insulin: $35 max
Most Brand

25% coinsurance
Insulin: $35 max
Additional Gap Coverage
Selected Medications

All Tier 6 drugs have additional coverage during Stage Three (Coverage Gap). Your cost will not increase from Stage two to Stage three. See the list of covered drugs to determine which drugs are included
STAGE FOUR After your out-of-pocket costs5 reach $8,000, you pay nothing for all drugs.
All Covered Drugs

$0


1 60-day supply copay is equal to two 30-day copays. You pay this amount for prescriptions written for 31-60 days.

2 90-day supply copay is equal to three 30-day copays. You pay this amount for prescriptions written for 61-90 days.

3 Limited to a 1-month (30-day) supply through in-network mail order or retail pharmacies.

4 Total Drug Costs: Both what you, and others on your behalf pay, and what PacificSource Medicare pays for your prescriptions.

5 Out-of-Pocket Costs: Everything you, and others on your behalf, have paid during Stage Two and Stage Three.


Included Dental Benefits

This plan covers dental care up to a yearly maximum of $500.

Coverage includes fillings, crowns, surgery, dentures, bridges, and other Class III services with 50% coinsurance. Preventive services like exams, cleanings, fluoride, and x-rays are covered with $0 copay.

You're free to see any dentist in the U.S., in or out of network. There is no deductible and no waiting period.

Optional Supplemental Dental

Comprehensive Dental Plan Benefits1
Premium $63
Annual Deductible $0
Annual Maximum Benefit $2,000
Diagnostic Services
(Preventive Class I)		 $0
Unlimited cleanings, exams, X-rays, fluoride, plus more
See Evidence of Coverage for details
Restorative & Extraction Services
(Basic Class II)		 20%
Fillings, oral surgery, pulpotomy, core build up, bone grafting, root planing, debridement, and sedation
Limitations apply, see Evidence of Coverage for details
Endodontics, periodontics, etc.
(Major Class III)		 50%
Crowns, inlays, onlays, dentures, bridges, denture relines, implants, oral surgery, periodontic surgery, and root canal therapy
Limitations apply, see Evidence of Coverage for details

1If you see a dentist outside the Advantage Dental Network, the out-of-network payment is based on the 85th percentile for Usual, Customary and Reasonable charges. If your dentist charges more than the maximum allowable charge, you will be responsible for the difference.


Over-the-Counter Benefit

Extra savings: With this plan, we'll reimburse you up to $100 per calendar year for over-the-counter aspirin, calcium, and calcium-vitamin D combinations.

No-cost Fitness Benefit

Silver and Fit logo The Silver&Fit® Healthy Aging and Exercise Program includes:

  • No-cost fitness center membership (premium clubs available at an additional monthly cost)
  • Thousands of on-demand workout videos
  • FitnessCoach® virtual personal fitness training
  • Customized workout plans and one-on-one coaching by phone, video, or chat

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

Hearing Benefits

TruHearing logo We've partnered with TruHearing® to provide comprehensive hearing care and high-quality hearing aids. Your benefit makes addressing hearing loss more affordable, with copays of $599 per aid for TruHearing Standard, $799 per aid for TruHearing Advanced, and $999 per aid for TruHearing Premium.

Hearing aid purchase includes:

  • A 60-day trial period
  • 1 year of follow-up visits for fitting and adjustments
  • 80 free batteries per non-rechargeable hearing aid
  • 3-year full manufacturer warranty

To learn more, visit TruHearing.com/PacificSource or call them at 844-255-7141.

Eyeglass and Vision Benefits

Your plan includes coverage for routine vision exams—a benefit not included in Original Medicare, which covers only medical eye exams. This plan also reimburses you for eyeglasses or contacts (up to a set amount), so you're free to choose the style you like.

The eyeglass allowance for this plan is $200 every two calendar years.

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. Subject to provider availability and limitations.

Post-Hospital Meal Delivery

Your plan includes 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

Global Emergency Assistance

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

Learn more at Assist America's website

Additional Benefits and Plan Features

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

  • Care Programs
    If you have a chronic health condition such as Diabetes, COPD, Congestive Heart Failure, or Asthma, you get personal attention to improve your health, overcome barriers, and coordinate your care.
  • Quality Improvement Programs
    Our in-network providers partner with us to improve your care and services. We use objective and subjective benchmarks to measure and evaluate quality and safety to ensure you’re getting the right care.
  • Health Screenings, Events, and Immunization Programs
    You get free health screenings, educational events, immunization programs and health risk assessments to help you manage chronic conditions and live the life you want.
  • Personal Medication Review
    Get free one-on-one consultations with a pharmacist to identify any safety issues, interactions, cost-savings, and other changes to improve your health. Your pharmacist will work with your doctor to help you get the most out of your coverage.

Plan Availability

The 2024 Explorer Rx 4 (PPO) Plan service area includes the following counties in Oregon:

  • Lane

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 your plan includes dental or you have purchased 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 .

Out-of-network/non-contracted providers are under no obligation to treat PacificSource Medicare’s members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call Customer Service or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Enrollment Resources

To find a plan that's right for you, we recommend you look at two or more plans, comparing their benefits, copays, coinsurance, monthly premiums, and prescription drug coverage. The links and documents below will help you decide on a plan.

Ready to enroll today? 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 at 866-282-8814 and we can enroll you over the phone.

If you prefer to meet with one of our friendly, knowledgeable people, you can visit our offices in Bend, Springfield, and Boise, Monday through Friday from 8:00 a.m. – 5:00 p.m. There is no appointment necessary.

  • View Summary of Benefits, updated 9/29/2023

    This Medicare Advantage plan includes all the benefits of Original Medicare, plus many more. The Summary of Benefits details what's covered by each plan.

  • Attend a Free Seminar

    Have questions about Medicare? Join us at one of our free eduational events.

  • 2024 PPO Plan Ratings
    , updated 10/24/2023

    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, updated 10/4/2023

    You can get an interpreter to answer any questions about our health or drug plans. To get an interpreter, call us at 888-863-3637. This is a free service.

  • Enrollment Form, updated 9/29/2023

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

Am I eligible to enroll in PacificSource Medicare?

You can enroll in a PacificSource Medicare Advantage plan 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 will tell you.

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

  2. You are already on Medicare

    You can enroll during the Annual Enrollment Period: 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
    • 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 a plan, you can follow the easy, step-by-step instructions at our enrollment center. Our online enrollment is confidential and secure.

If you have questions, or would like someone to walk you through the process, we have local, knowledgeable people here to assist.

Call us at 866-282-8814.
Email: MedicareSales@PacificSource.com

You can get in-person help at our offices in Bend, Springfield, and Boise.


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.

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.

    Example: If your Medicare coverage begins 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

    Example: If you enroll between October 15 and December 7, 2024, your coverage would begin January 1, 2025.

There may be other exceptions. Please contact us for details.


After Enrollment

Once you enroll in a PacificSource Medicare plan, we will send your enrollment form to the Centers for Medicare & Medicaid Services (CMS) for approval. When 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 contact us.

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

Out-of-network/non-contracted providers are under no obligation to treat PacificSource Medicare’s members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call Customer Service or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

What Is Medicare?

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

The Parts of Medicare: A, B, C & D

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 once they start receiving 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 65; includes the month you turn 65; and ends 3 months after the month you turn 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 such as HMOs and PPOs. PacificSource offers Medicare Advantage Plans. Part C is administered by insurers such as PacificSource under contract with Medicare. These plans include both Medicare Part A and Part B in one convenient plan, and fill in some of the gaps in Medicare coverage. Some plans also include Part D Prescription drug coverage and preventive dental in a single plan. Most people will pay a monthly premium for Part C 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 by 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, call:

  • 800-MEDICARE (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 have only original Medicare:

Part B (Medical)

  • $174.70 monthly premium*
  • $240 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)

  • $1,632 deductible per benefit period
  • $0 per day (days 1-60)
  • $408 per day (days 61-90)
  • $816 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

*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 800-MEDICARE (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:

  • Care received outside the United States
  • Outpatient prescription drugs

Also, note that not all doctors accept Original Medicare, and there is no annual limit on your total out-of-pocket expenses.


Medicare Advantage and Medicare Supplement

If you want extra coverage in additional to Original Medicare, you can purchase it either through a Medicare Advantage plan or with a Medicare Supplement plan. With both plans, you are still on Medicare. Here are the main differences:

Medicare Advantage Plan (such as PacificSource Medicare plans)
These plans fill in the gaps by covering some of the costs Medicare does not cover. We provide more benefits than Medicare alone, or Medigap plans. And we provide personal service to make it easy.

We offer a variety of plans, including low-priced plans to help save you money. You can also get the convenience of plans that include medical (Part A and Part B) and prescription drug coverage (Part D) all in one plan. Most of our Medicare Advantage plans include dental benefits. You also have the option to add supplemental dental coverage for an additional monthly premium. For those who qualify for both Medicare and Medicaid, we also offer a PacificSource Dual Care, an HMO D-SNP plan.

Finding a doctor is easy, because nearly every doctor in the region accepts PacificSource. And, with all our PPO and HMO-POS plans, you have the freedom to see any doctor who accepts Medicare in the United States. You're also 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 dental coverage. The doctor's office will bill us. 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 have less paperwork.

Monthly premiums are the same for all ages. Everyone on a particular 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 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 want prescription coverage, you would need to purchase a Part D plan in addition to your Medigap plan.

Not all doctors accept Original Medicare. If your doctor does not accept Original Medicare, 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 see a doctor, you must bring two ID cards: your red, white, and blue Medicare card and your Medigap card. The doctor will send bills to two places: first to Medicare to pay their portion, then to your Medigap plan to pay the plan's portion.

With Medigap, monthly premiums are based on your age.


Want to Learn More About Medicare?

Call 800-MEDICARE (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.