PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) H3864-029 is a 2023 Medicare Advantage Plan or Part-C by PacificSource Medicare available to residents in Montana. This plan includes extra prescription drug (Part-D) coverage. PacificSource Medicare 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 an extremely nice safety net.

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 extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from PacificSource Medicare and not Original Medicare. With 2023 Medicare Advantage Plan 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 if you sign up for Medicare Advantage in Montana.

2023 PacificSource Medicare Medicare Advantage Plan Overview

What type of plan is PacificSource Medicare MyCare Choice Rx 29 (HMO-POS)

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 primary care physician 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 primary care physician approval, called a referral. Services received from an out-of-network provider are not typically covered.

With a HMO-POS point-of-service you have the option to go out-of-network or see a specialist without a referral. But, you may pay more for out-of-network care you receive than from an in-network provider.

How much does PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) cost?

Monthly Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. PacificSource Medicare charges a $0 consolidated premium. The Part C premium is $0 this charge covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) has a monthly drug premium of $0 and a $150.00 drug deductible. This PacificSource Medicare plan offers a $0 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. This Premium covers any enhanced plan benefits offered by PacificSource Medicare above and beyond the standard PDP benefits. This can include extra coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $0. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

PacificSource Medicare Gap Coverage

In 2023 once you and your plan provider have spent $4660 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 extra coverage. This PacificSource Medicare plan does offer extra coverage through the gap.

MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) by PacificSource Medicare MOOP is $5,200. Once you spend $5,200 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.

Formulary and 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.

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

The complete PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) Formulary.
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from PacificSource Medicare helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)	Covered

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Contact lenses

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

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Eyeglass frames

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

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Eyeglass lenses

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

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Eyeglasses (frames and lenses)

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

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Other

In-Network Vision	$0 copay
Out-of-Network Vision	50% coinsurance

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Routine eye exam

Out-of-Network Vision	50% coinsurance
In-Network Vision	$0 copay

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Upgrades

Vision	Not covered

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Transportation	Not covered
In-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $196 per day for days 21 through 100
Out-of-Network Skilled Nursing Facility	50% per stay

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Occupational therapy visit

In-Network Rehabilitation services	$40 copay
Out-of-Network Rehabilitation services	$45 copay or 50% coinsurance

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Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	$40 copay
Out-of-Network Rehabilitation services	$45 copay or 50% coinsurance

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Cleaning

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$45 copay or 50% coinsurance

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Dental x-ray(s)

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$45 copay or 50% coinsurance

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Fluoride treatment

Preventive dental	Not covered

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Oral exam

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$45 copay or 50% coinsurance

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In-Network Preventive care	$0 copay
Out-of-Network Preventive care	50% coinsurance
In-Network Outpatient hospital coverage	$0-360 copay per visit
Out-of-Network Outpatient hospital coverage	50% coinsurance per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	Yes

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Inpatient hospital - psychiatric

In-Network Mental health services	$320 per day for days 1 through 5 $0 per day for days 6 through 90
Out-of-Network Mental health services	50% per stay

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Outpatient group therapy visit

Out-of-Network Mental health services	50% coinsurance
In-Network Mental health services	$40 copay

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Outpatient group therapy visit with a psychiatrist

Out-of-Network Mental health services	50% coinsurance
In-Network Mental health services	$40 copay

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Outpatient individual therapy visit

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	50% coinsurance

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Outpatient individual therapy visit with a psychiatrist

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	50% coinsurance

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Chemotherapy

Out-of-Network Medicare Part B drugs	50% coinsurance
In-Network Medicare Part B drugs	20% coinsurance

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Other Part B drugs

Out-of-Network Medicare Part B drugs	50% coinsurance
In-Network Medicare Part B drugs	20% coinsurance

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Diabetes supplies

Out-of-Network Medical equipment/supplies	50% coinsurance per item
In-Network Medical equipment/supplies	20% coinsurance per item

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Durable medical equipment (e.g., wheelchairs, oxygen)

Out-of-Network Medical equipment/supplies	50% coinsurance per item
In-Network Medical equipment/supplies	20% coinsurance per item

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Prosthetics (e.g., braces, artificial limbs)

Out-of-Network Medical equipment/supplies	50% coinsurance per item
In-Network Medical equipment/supplies	0-20% coinsurance per item

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$5,200 In-network
Out-of-Network Inpatient hospital coverage	50% per stay
In-Network Inpatient hospital coverage	$360 per day for days 1 through 5 $0 per day for days 6 through 90

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Fitting/evaluation

In-Network Hearing	$0 copay
Out-of-Network Hearing	$0 copay

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Hearing aids

In-Network Hearing	$599-999 copay
Out-of-Network Hearing	$599-999 copay

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Hearing exam

In-Network Hearing	$40 copay
Out-of-Network Hearing	50% coinsurance

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Health plan deductible	$0
Out-of-Network Ground ambulance	$300 copay
In-Network Ground ambulance	$300 copay

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Foot exams and treatment

In-Network Foot care (podiatry services)	$40 copay
Out-of-Network Foot care (podiatry services)	50% coinsurance

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Routine foot care

Foot care (podiatry services)	Not covered

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Emergency

Emergency care/Urgent care	$110 copay per visit (always covered)

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Urgent care

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

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Primary

In-Network Doctor visits	$0 copay
Out-of-Network Doctor visits	$45 copay or 50% coinsurance per visit

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Specialist

In-Network Doctor visits	$0-40 copay per visit
Out-of-Network Doctor visits	$45 copay or 50% coinsurance per visit

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Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	$0-450 copay
Out-of-Network Diagnostic procedures/lab services/imaging	50% coinsurance

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Diagnostic tests and procedures

Out-of-Network Diagnostic procedures/lab services/imaging	50% coinsurance
In-Network Diagnostic procedures/lab services/imaging	$40 copay or 20% coinsurance

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Lab services

In-Network Diagnostic procedures/lab services/imaging	$0-40 copay or 20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging	50% coinsurance

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Outpatient x-rays

Out-of-Network Diagnostic procedures/lab services/imaging	50% coinsurance
In-Network Diagnostic procedures/lab services/imaging	$0-40 copay

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Diagnostic services

Comprehensive dental	Not covered

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Endodontics

Comprehensive dental	Not covered

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Extractions

In-Network Comprehensive dental	30% coinsurance
Out-of-Network Comprehensive dental	30% coinsurance

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Non-routine services

Comprehensive dental	Not covered

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Periodontics

Comprehensive dental	Not covered

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Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental	Not covered

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Restorative services

Out-of-Network Comprehensive dental	30% coinsurance
In-Network Comprehensive dental	30% coinsurance

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In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	No

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

Is PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) a good plan? PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) received a 3.5 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well Medicare Advantage and Part D plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance. Medicare Advantage with prescription drug (Part D) coverage (MA-PD) contracts are rated on up to 38 unique quality and performance measures. You can use the CMS star rating to compare PacificSource Medicare MyCare Choice Rx 29 Reviews among several different plans.

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with H3864-029 Health Plan

Member Complaints and Changes in Plans Performance

Health Plan Customer Service Rating for PacificSource Medicare

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

Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) requires you to live in that plan’s service area. The service area is listed below:

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Source:CMS. Data as of Oct 1, 2022.

Last updated on December 03, 2022

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.