PacificSource Medicare Explorer 12 (PPO)
Medicare Plan Details
2020 Plan
Monthly Premium
| (select county for price) |
by PacificSource Medicare
Additional Coverage
Hearing
Vision
Overall Government Star Rating
3.5out of 5 stars
State: Idaho
Select your county to view the price for this plan
Plan Type
Medicare Advantage (Part C)
Medicare Advantage combines Part A and Part B. This plan = Part A + Part B
Plan Details
$0
$0
$0
$0
$10,000 In and Out-of-network
$6,700 In-network
$6,700 In-network
No
Yes
Yes
No
Medical Benefits
Doctor Services
In-network: $0-10 per visit
Out-of-network: 50% per visit
Out-of-network: 50% per visit
In-network: $0-35 per visit
Out-of-network: 50% per visit
Out-of-network: 50% per visit
Tests, labs, & imaging
In-network: $15 or 20%
Out-of-network: 50%
Out-of-network: 50%
In-network: $0-15 or 20%
Out-of-network: 50%
Out-of-network: 50%
In-network: $190-310
Out-of-network: 50%
Out-of-network: 50%
In-network: $0-15
Out-of-network: 50%
Out-of-network: 50%
$90 per visit (always covered)
$40 per visit (always covered)
Hospital Services
In-network: $285 per day for days 1 through 7
$0 per day for days 8 through 90
Out-of-network: 50% per stay
$0 per day for days 8 through 90
Out-of-network: 50% per stay
In-network: $0-285 per visit
Out-of-network: 50% per visit
Out-of-network: 50% per visit
Skilled nursing facility
In-network: $0 per day for days 1 through 20
$178 per day for days 21 through 100
Out-of-network: 50% per stay
50% per day for days 1 through 100
$178 per day for days 21 through 100
Out-of-network: 50% per stay
50% per day for days 1 through 100
Preventive services
In-network: $0 copay
Out-of-network: 50%
Out-of-network: 50%
Ambulance
In-network: $250
Out-of-network: $250
Out-of-network: $250
Therapy services
In-network: $35
Out-of-network: 50%
Out-of-network: 50%
In-network: $35
Out-of-network: 50%
Out-of-network: 50%
Mental health services
In-network: $25
Out-of-network: 50%
Out-of-network: 50%
In-network: $25
Out-of-network: 50%
Out-of-network: 50%
In-network: $25
Out-of-network: 50%
Out-of-network: 50%
In-network: $25
Out-of-network: 50%
Out-of-network: 50%
Opioid treatment services
Covered
Other services
In-network: 20% per item
Out-of-network: 50% per item
Out-of-network: 50% per item
In-network: 0-20% per item
Out-of-network: 50% per item
Out-of-network: 50% per item
In-network: $0 copay
Out-of-network: 50% per item
Out-of-network: 50% per item
Prescription Drug Benefits
Tier drug costs for: Standard retail pharmacy drug cost for 1-month
Part B Drugs
In-network: 20%
Out-of-network: 50%
Out-of-network: 50%
In-network: 20%
Out-of-network: 50%
Out-of-network: 50%
Extra Benefits
Hearing
In-network: $35
Out-of-network: 50%
Out-of-network: 50%
Not covered
In-network: $699-999
Out-of-network: $699-999
Out-of-network: $699-999
Preventive Dental
Not covered
Not covered
Not covered
Not covered
Comprehensive dental
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Vision
In-network: $35
Out-of-network: $35 or 50%
Out-of-network: $35 or 50%
In-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Not covered
Other benefits
Limited coverage
Limited coverage
Not covered
Not covered
Not covered
Limited coverage
Limited coverage
Health Plan Star Ratings
(government star ratings are out of 5 stars)
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