2022 PacificSource Medicare Explorer 16 (PPO)

PacificSource Medicare Explorer 16 (PPO) H4754-016 is a 2022 Medicare Advantage Plan or Part-C by PacificSource Medicare available to residents in Montana. This plan does not provide additional prescription drug (Part-D) coverage. The PacificSource Medicare Explorer 16 (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $5,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,900 out-of-pocket. This can be a extremely nice safety net.

PacificSource Medicare Explorer 16 (PPO) is a Local PPO *. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

PacificSource Medicare works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for PacificSource Medicare Explorer 16 (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from PacificSource Medicare and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from PacificSource Medicare except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 PacificSource Medicare Medicare Advantage Plan Costs

2021 PacificSource Medicare Explorer 16 (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	50% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$190-310 copay
Diagnostic tests and procedures	$15 copay or 20% coinsurance
Diagnostic tests and procedures	50% coinsurance (Out-of-Network)
Lab services	50% coinsurance (Out-of-Network)
Lab services	$0-15 copay or 20% coinsurance
Outpatient x-rays	$0-15 copay
Outpatient x-rays	50% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$0-10 copay per visit
Primary	50% coinsurance per visit (Out-of-Network)
Specialist	$0-35 copay per visit
Specialist	50% coinsurance per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$40 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$35 copay
Foot exams and treatment	50% coinsurance (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$250 copay
$250 copay or 20% coinsurance (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	$0 copay (Out-of-Network)
Hearing aids	$699-999 copay (Out-of-Network)
Hearing aids	$699-999 copay
Hearing exam	50% coinsurance (Out-of-Network)
Hearing exam	$35 copay

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Inpatient Hospital Coverage

50% per stay (Out-of-Network)
$285 per day for days 1 through 7 $0 per day for days 8 through 90

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Medical Equipment/Supplies

Diabetes supplies	$0 copay
Diabetes supplies	50% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	50% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	0-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	50% coinsurance per item (Out-of-Network)

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Medicare Part B Drugs

Chemotherapy	50% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance
Other Part B drugs	50% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	$230 per day for days 1 through 7 $0 per day for days 8 through 90
Inpatient hospital - psychiatric	50% per stay (Out-of-Network)
Outpatient group therapy visit	$25 copay
Outpatient group therapy visit	50% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$25 copay
Outpatient group therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$25 copay
Outpatient individual therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$25 copay

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MOOP

$10,000 In and Out-of-network $6,700 In-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

50% coinsurance per visit (Out-of-Network)
$0-285 copay per visit

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Package #1

Deductible
Monthly Premium	$23.00

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Package #2

Deductible	$100.00
Monthly Premium	$49.00

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Preventive Care

$0 copay
50% coinsurance (Out-of-Network)

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Preventive Dental

Cleaning	Not covered
Dental x-ray(s)	Not covered
Fluoride treatment	Not covered
Oral exam	Not covered

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Rehabilitation Services

Occupational therapy visit	50% coinsurance (Out-of-Network)
Occupational therapy visit	$35 copay
Physical therapy and speech and language therapy visit	50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$35 copay

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Skilled Nursing Facility

50% per stay 50% per day for days 1 through 100 (Out-of-Network)
$0 per day for days 1 through 20 $184 per day for days 21 through 100

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Transportation

Not covered

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Vision

Contact lenses	$0 copay (Out-of-Network)
Contact lenses	$0 copay
Eyeglass frames	$0 copay (Out-of-Network)
Eyeglass frames	$0 copay
Eyeglass lenses	$0 copay
Eyeglass lenses	$0 copay (Out-of-Network)
Eyeglasses (frames and lenses)	$0 copay (Out-of-Network)
Eyeglasses (frames and lenses)	$0 copay
Other	$35 copay or 50% coinsurance (Out-of-Network)
Other	$0 copay
Routine eye exam	$35 copay
Routine eye exam	$35 copay or 50% coinsurance (Out-of-Network)
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for PacificSource Medicare Explorer 16 (PPO) H4754

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in PacificSource Medicare Explorer 16 (PPO) Plans Performance

Health Plan Customer Service Rating for PacificSource Medicare Explorer 16 (PPO)

PacificSource Medicare Explorer 16 (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for PacificSource Medicare Explorer 16 (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.