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2023 PacificSource Medicare MyCare Choice Rx 29 (HMO-POS)

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

Name:PacificSource Medicare MyCare Choice Rx 29 (HMO-POS)
Plan ID:H3864 029 0
Provider:PacificSource Medicare
Year:2023
Type:Local HMO
Combined Premium (C+D):$0/mo
Part C Premium:$0/mo
MOOP:$5,200/yr
Part D (Drug) Premium:$0/mo
Part D Supplemental Premium$0/mo
Total Part D Premium:$0/mo
Drug Deductible:$150.00/yr
Tiers with No Deductible:1
Gap Coverage:Yes
Benchmark:Not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H3864-030




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


Contact lenses


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


Eyeglass frames


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


Eyeglass lenses


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


Eyeglasses (frames and lenses)


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


Other


In-Network Vision$0 copay
Out-of-Network Vision50% coinsurance


Routine eye exam


Out-of-Network Vision50% coinsurance
In-Network Vision$0 copay


Upgrades


VisionNot covered



TransportationNot 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 Facility50% per stay


Occupational therapy visit


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


Physical therapy and speech and language therapy visit


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


Cleaning


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


Dental x-ray(s)


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


Fluoride treatment


Preventive dentalNot covered


Oral exam


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



In-Network Preventive care$0 copay
Out-of-Network Preventive care50% coinsurance
In-Network Outpatient hospital coverage$0-360 copay per visit
Out-of-Network Outpatient hospital coverage50% coinsurance per visit
In-Network Other health plan deductibles?No
Optional supplemental benefitsYes


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 services50% per stay


Outpatient group therapy visit


Out-of-Network Mental health services50% coinsurance
In-Network Mental health services$40 copay


Outpatient group therapy visit with a psychiatrist


Out-of-Network Mental health services50% coinsurance
In-Network Mental health services$40 copay


Outpatient individual therapy visit


In-Network Mental health services$40 copay
Out-of-Network Mental health services50% coinsurance


Outpatient individual therapy visit with a psychiatrist


In-Network Mental health services$40 copay
Out-of-Network Mental health services50% coinsurance


Chemotherapy


Out-of-Network Medicare Part B drugs50% coinsurance
In-Network Medicare Part B drugs20% coinsurance


Other Part B drugs


Out-of-Network Medicare Part B drugs50% coinsurance
In-Network Medicare Part B drugs20% coinsurance


Diabetes supplies


Out-of-Network Medical equipment/supplies50% coinsurance per item
In-Network Medical equipment/supplies20% coinsurance per item


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


Out-of-Network Medical equipment/supplies50% coinsurance per item
In-Network Medical equipment/supplies20% coinsurance per item


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


Out-of-Network Medical equipment/supplies50% coinsurance per item
In-Network Medical equipment/supplies0-20% coinsurance per item



Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$5,200 In-network
Out-of-Network Inpatient hospital coverage50% per stay
In-Network Inpatient hospital coverage$360 per day for days 1 through 5
$0 per day for days 6 through 90


Fitting/evaluation


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


Hearing aids


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


Hearing exam


In-Network Hearing$40 copay
Out-of-Network Hearing50% coinsurance



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


Foot exams and treatment


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


Routine foot care


Foot care (podiatry services)Not covered


Emergency


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


Urgent care


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


Primary


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


Specialist


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


Diagnostic radiology services (e.g., MRI)


In-Network Diagnostic procedures/lab services/imaging$0-450 copay
Out-of-Network Diagnostic procedures/lab services/imaging50% coinsurance


Diagnostic tests and procedures


Out-of-Network Diagnostic procedures/lab services/imaging50% coinsurance
In-Network Diagnostic procedures/lab services/imaging$40 copay or 20% coinsurance


Lab services


In-Network Diagnostic procedures/lab services/imaging$0-40 copay or 20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging50% coinsurance


Outpatient x-rays


Out-of-Network Diagnostic procedures/lab services/imaging50% coinsurance
In-Network Diagnostic procedures/lab services/imaging$0-40 copay


Diagnostic services


Comprehensive dentalNot covered


Endodontics


Comprehensive dentalNot covered


Extractions


In-Network Comprehensive dental30% coinsurance
Out-of-Network Comprehensive dental30% coinsurance


Non-routine services


Comprehensive dentalNot covered


Periodontics


Comprehensive dentalNot covered


Prosthodontics, other oral/maxillofacial surgery, other services


Comprehensive dentalNot covered


Restorative services


Out-of-Network Comprehensive dental30% coinsurance
In-Network Comprehensive dental30% coinsurance



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.

2022 Overall Rating
Part C Summary Rating
Part-D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Pain Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy


Member Experience with H3864-029 Health Plan

Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


Health Plan Customer Service Rating for PacificSource Medicare

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes


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:

State: Montana Medicare
County:Yellowstone County MA Plans



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

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

How much is PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) 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.

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 you will be required to receive most of your health care from an in-network provider. HMOs require that you select a primary care physician (PCP).

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.

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 plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance.



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

Last updated on

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.

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Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

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