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Call for a quote, to enroll, or for more info: 866-282-8814, TTY 711

2022 MyCare Rx 40 (HMO) Plan


This plan's premium is $0

This Medicare Advantage plan fills in the gaps and covers more services than Medicare alone. You also get the convenience of both medical and prescription drug coverage all in one plan. Find out what your costs would be for covered medications by clicking on Drug Search.

This is a Medicare Advantage HMO (Health Maintenance Organization) plan. This plan utilizes the Legacy Health Partners network and includes other independent providers such as Northwest Primary Care, The Portland Clinic, South Tabor Family Physicians and The Vancouver Clinic. As a member of this plan, you must use this network to receive in-network benefits for your medical care and services. Services received outside this network are not covered. 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.



2022 MyCare Rx 40 (HMO)
$0 per month
Benefit Highlights In-Network
Annual Medical Deductible $0
Referrals No Referrals Required
Annual Out-of-Pocket Maximum
(Medical)
$4,950
Primary Care Provider $0 copay
Specialist $30 copay
Laboratory Lab $20 copay
Genetic testing 20% coinsurance
X-ray $15 copay
Advanced Diagnostics CT Scan & Nuclear $235 copay
MRI & PET Scan $320 copay
Hospitalization $380/day (1-5)
$0/day (6+)
Outpatient Surgery $235 copay
Physical Therapy $30 copay
Skilled Nursing Facility $0/day(1-20)
$188/day (21-100)
Durable Medical Equipment 20% coinsurance
Ambulance (Ground and Air) $325 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
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 $0 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
$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 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) $325 copay
Part D Prescription Drug Benefits Preferred Pharmacies Standard Pharmacies
STAGE ONE
Deductible

$0

STAGE TWO
Tier 1
Preferred Generic

$0 copay 30-day supply1,2

$8 copay 30-day supply1,2

Tier 2
Generic

$9 copay 30-day supply1,2

$17 copay 30-day supply1,2

Tier 3
Preferred Brand

$37 copay 30-day supply1,2

$47 copay 30-day supply1,2

Tier 4
Non-Preferred Drug

31% coinsurance

33% coinsurance

Tier 5
Specialty

33% coinsurance3

Tier 6
Select Care Drugs

$0 copay 30-day supply

STAGE THREE What you pay after total drug costs4 reach $4,430
Most Generic

25% coinsurance

Most Brand

25% coinsurance

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 $7,050, the maximum you pay until the end of the calendar year
All Covered Drugs

You pay whichever is the larger amount:
5% coinsurance -or- $3.95 generic drugs $9.85 all other drugs


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

2 100-day supply copay is equal to three 30-day copays. You pay this amount for prescriptions written for 61-100 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.

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


Optional Comprehensive Dental


Comprehensive Dental Plan Benefits1
Premium $57
Annual Deductible $0
Annual Maximum Benefit $1,000
Diagnostic Services
(Preventive Class I)
$0
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)
20%
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)
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

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.


$0 Fitness Benefit


Silver and Fit logo 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:

  • A no-cost fitness center/YMCA membership at a participating location
  • One Home Fitness Kit per benefit year with wearable fitness tracker option
  • Digital workout videos on the Silver&Fit website or mobile app
  • Healthy Aging Coaching
  • And other member resources

Learn more at 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 ($599, $799, or $999)
    • 80 batteries included with nonrechargable models
    • 60 day money back guarantee*
    • 3-year extended warranty
    • First year of follow-up provider visits

* 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.

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. 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.

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
Mammogram $25
Diabetic A1c (blood glucose test) $15 - First test
$25 - Second test
Diabetic eye exam $25
Flu shot $10
Dexa Scan $20
Colonoscopy or Fit Kit $20

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 a full list of participating retailers, click here. To redeem your certificate, 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

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

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.

Over-the-Counter Benefits


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 2022 MyCare Rx 40 (HMO) Plan service area includes the following counties in Oregon:

  • Clackamas
  • Multnomah
  • Washington

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 .

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).

  • 2022 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, 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.

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)

  • $170.10 monthly premium*
  • $233 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)

  • $1,556 deductible per benefit period
  • $0 per day (days 1-60)
  • $389 per day (days 61-90)
  • $778 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 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. 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.


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.