2022 PacificSource Medicare MyCare Choice Rx 29 (HMO-POS)

PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) H3864-029 is a 2022 Medicare Advantage Plan or Part-C by PacificSource Medicare available to residents in Montana. This plan includes additional prescription drug (Part-D) coverage. The PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $5,200 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,200 out-of-pocket. This can be a extremely nice safety net.

PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered.

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 MyCare Choice Rx 29 (HMO-POS) 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

PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) Part-C Premium

PacificSource Medicare charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H3864-029 Part-D Deductible and Premium

PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) has a monthly drug premium of $0.00 and a $150.00 drug deductible. This PacificSource Medicare plan offers a $0.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by PacificSource Medicare above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

PacificSource Medicare Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This PacificSource Medicare plan does offer additional coverage through the gap.

H3864-029 Formulary or Drug Coverage

PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) H3864-029 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$3	$8
Tier 2	$12	$17
Tier 3	$37	$47
Tier 4	31%	33%
Tier 5	30%	30%
Tier 6	$0	$0

*Initial Coverage Phase and 30 day supply

2021 PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) 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)	$300-450 copay
Diagnostic tests and procedures	$40 copay or 20% coinsurance
Diagnostic tests and procedures	50% coinsurance (Out-of-Network)
Lab services	50% coinsurance (Out-of-Network)
Lab services	$0-40 copay or 20% coinsurance
Outpatient x-rays	$0-40 copay
Outpatient x-rays	50% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$0 copay
Primary	50% coinsurance per visit (Out-of-Network)
Specialist	$0-40 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	$40 copay
Foot exams and treatment	50% coinsurance (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$275 copay
$275 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	$40 copay

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Inpatient Hospital Coverage

50% per stay (Out-of-Network)
$360 per day for days 1 through 5 $0 per day for days 6 through 90

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Medical Equipment/Supplies

Diabetes supplies	20% coinsurance per item
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	$320 per day for days 1 through 5 $0 per day for days 6 through 90
Inpatient hospital - psychiatric	50% per stay (Out-of-Network)
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit	50% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 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	$40 copay
Outpatient individual therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay

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MOOP

$5,200 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)
$0-360 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	$40 copay
Physical therapy and speech and language therapy visit	50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$40 copay

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Skilled Nursing Facility

50% per stay (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	$40 copay or 50% coinsurance (Out-of-Network)
Other	$0 copay
Routine eye exam	$40 copay
Routine eye exam	$40 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 MyCare Choice Rx 29 (HMO-POS) H3864

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 MyCare Choice Rx 29 (HMO-POS) Plans Performance

Health Plan Customer Service Rating for PacificSource Medicare MyCare Choice Rx 29 (HMO-POS)

PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) 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 MyCare Choice Rx 29 (HMO-POS)

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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.