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.
|2022 Essentials 2* (HMO)
$0 per month
|Referrals||No Referrals Required|
|Annual Out-of-Pocket Maximum
|Primary Care Provider||$0 copay|
|Laboratory||Lab $15 copay
Genetic testing 20% coinsurance
|Advanced Diagnostics||CT Scan & Nuclear $190 copay
MRI & PET Scan $310 copay
|Outpatient Surgery||$325 copay|
|Physical Therapy||$0 copay|
|Skilled Nursing Facility||$0/day(1-20)
|Durable Medical Equipment||20% coinsurance|
|Ambulance (Ground and Air)||$300 copay|
|Part B Drugs
|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)
|Pap and Pelvic Exams||$0 copay|
|Annual Wellness Visit||$0 copay|
|Diabetes Screening||$0 copay|
|Preventive Dental||$0 copay
$500 maximum benefit limit
|Comprehensive Dental||30% coinsurance
$500 maximum benefit limit combined with Preventive Dental
|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 2 calendar years
|24-Hour NurseLine||$0 copay|
|Silver&Fit© Fitness Program||$0 copay
fitness facility & home fitness kit
|Alternative Care||$25 copay limit 12 visits/year, combined
(non-Medicare covered acupuncture, naturopathy, and chiropractic)
|Chronic Care Management
Transitional Care Management
|Over-the-Counter (OTC)||$100 benefit limit
covered once every calendar year
|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||Included
Up to $190 in rewards, see Summary of Benefits for details
|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.
|Comprehensive Dental Plan Benefits1|
|Annual Maximum Benefit||$1,000|
(Preventive Class I)
2 cleanings, 2 exams, and 2 X-rays per calendar year, plus more
See Evidence of Coverage for details
|Restorative & Extraction Services
(Basic Class II)
Fillings, crowns, 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)
Crowns, inlays, onlays, dentures, bridges, denture relines, implants, oral surgery, periodontic surgery, and root canal therapy
Limitations apply, see Evidence of Coverage for details
1 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. There are no waiting periods.
As a member, you can enjoy the Silver&Fit® Healthy Aging and Fitness program at no additional cost beyond your monthly premium. Or for an additional buy-up price, you can join a Premium location.
The Silver&Fit program gives you the digital tools and personalized support you need to enjoy a better life balance. This benefit includes:
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.
Good hearing is important to your health. That’s why PacificSource Medicare partners with TruHearing to offer a hearing hardware benefit. This plan includes*:
* Hearing aid repairs and replacements are subject to provider and manufacturer fees. For questions regarding fees, contact TruHearing customer service.
For information, visit TruHearing.com/PacificSource or call 844-255-7141, TTY 711.
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.
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.
Rewards may be earned once per calendar year, except for colonoscopy, which is eligible for a reward once every 10 years.
|Routine physical or annual wellness visit||$50|
|Diabetic A1c (blood glucose test)||$15 - First test
$25 - Second test
|Diabetic eye exam||$25|
|Colonoscopy or Fit Kit||$20|
A few key details
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.
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:
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.
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.
The following benefits and services are available to PacificSource Medicare members at no additional cost:
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.
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.
You can enroll in PacificSource Medicare if:
You can join a PacificSource Medicare plan when:
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.
You are already on Medicare.
You can enroll between October 15 – December 7
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:
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.
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:
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.
If you are already enrolled in another plan, you can enroll in a PacificSource Medicare plan during the Annual Enrollment Period:
If you enroll between October 15 – December 7, 2022, your coverage would begin January 1, 2023.
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.
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:
Below are some of the costs you will pay if you only had original Medicare:
Part B (Medical)
Part A (Hospital)
Part D (Prescription)
* 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.
There are some limitations to Original Medicare. In most cases, the following are not covered:
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. Most of our Medicare Advantage plans include dental benefits. We also have the option to add preventive or comprehensive dental coverage for an additional monthly premium. For those who qualify for both Medicare and Medicaid, we also offer a dual special needs plan.
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.
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.