PacificSource Medicare Explorer 12 (PPO)
Medicare Plan Details
2021 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
$3,500 In-network
$3,500 In-network
No
Yes
Yes
No
Medical Benefits
Doctor Services
In-network: $0 copay
Out-of-network: 50% coinsurance per visit
Out-of-network: 50% coinsurance per visit
In-network: $0-35 copay per visit
Out-of-network: 50% coinsurance per visit
Out-of-network: 50% coinsurance per visit
Tests, labs, & imaging
In-network: $15 copay or 20% coinsurance
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
In-network: $0-15 copay or 20% coinsurance
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
In-network: $190-310 copay
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
In-network: $0-15 copay
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
$90 copay per visit (always covered)
$40 copay 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 copay per visit
Out-of-network: 50% coinsurance per visit
Out-of-network: 50% coinsurance per visit
Skilled nursing facility
In-network: $0 per day for days 1 through 20
$184 per day for days 21 through 100
Out-of-network: 50% per stay
50% per day for days 1 through 100
$184 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% coinsurance
Out-of-network: 50% coinsurance
Ambulance
In-network: $250 copay
Out-of-network: $250 copay
Out-of-network: $250 copay
Therapy services
In-network: $35 copay
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
In-network: $35 copay
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Mental health services
In-network: $25 copay
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
In-network: $25 copay
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
In-network: $25 copay
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
In-network: $25 copay
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Opioid treatment services
Covered
Other services
In-network: 20% coinsurance per item
Out-of-network: 50% coinsurance per item
Out-of-network: 50% coinsurance per item
In-network: 0-20% coinsurance per item
Out-of-network: 50% coinsurance per item
Out-of-network: 50% coinsurance per item
In-network: $0 copay
Out-of-network: 50% coinsurance per item
Out-of-network: 50% coinsurance per item
Prescription Drug Benefits
Tier drug costs for: Standard retail pharmacy drug cost for 1-month
Part B Drugs
In-network: 20% coinsurance
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
In-network: 20% coinsurance
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Extra Benefits
Hearing
In-network: $35 copay
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
In-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
In-network: $699-999 copay
Out-of-network: $699-999 copay
Out-of-network: $699-999 copay
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 copay
Out-of-network: $35 copay or 50% coinsurance
Out-of-network: $35 copay or 50% coinsurance
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
Limited coverage
Limited coverage
Limited coverage
Health Plan Star Ratings
(government star ratings are out of 5 stars)
When Can I Sign Up for Medicare?
Enter your birthday month and year to learn when you can sign up for different Medicare plan options.
Advertisement
Medicare Signup Help
Quote & Compare
Find your plan online or speak with a licensed insurance agent to compare your options and get help signing up for the right plan for you!