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

3.5

out 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

Monthly Premium

Health Portion of Premium

Drug Portion of Premium

Health Plan Deductible

Health Plan Max Out-of-Pocket

$10,000 In and Out-of-network
$3,500 In-network

Nationwide Coverage included

Hearing Coverage included

Yes

Vision Coverage included

Yes

Dental Coverage included

Doctor Lookup Link

http://www.Medicare.PacificSource.com

Plan Link

http://www.Medicare.PacificSource.com

Medical Benefits

Doctor Services

Primary doctor visit

In-network: $0 copay
Out-of-network: 50% coinsurance per visit

Specialist visit

In-network: $0-35 copay per visit
Out-of-network: 50% coinsurance per visit

Tests, labs, & imaging

Diagnostic tests & procedures

In-network: $15 copay or 20% coinsurance
Out-of-network: 50% coinsurance

Lab services

In-network: $0-15 copay or 20% coinsurance
Out-of-network: 50% coinsurance

Diagnostic radiology services (like MRI)

In-network: $190-310 copay
Out-of-network: 50% coinsurance

Outpatient x-rays

In-network: $0-15 copay
Out-of-network: 50% coinsurance

Emergency care

$90 copay per visit (always covered)

Urgent care

$40 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage

In-network: $285 per day for days 1 through 7
$0 per day for days 8 through 90
Out-of-network: 50% per stay

Outpatient hospital coverage

In-network: $0-285 copay 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

Preventive services

In-network: $0 copay
Out-of-network: 50% coinsurance

Ambulance

Ground ambulance

In-network: $250 copay
Out-of-network: $250 copay

Therapy services

Occupational therapy visit

In-network: $35 copay
Out-of-network: 50% coinsurance

Physical therapy & speech & language therapy visit

In-network: $35 copay
Out-of-network: 50% coinsurance

Mental health services

Outpatient group therapy with a psychiatrist

In-network: $25 copay
Out-of-network: 50% coinsurance

Outpatient individual therapy with a psychiatrist

In-network: $25 copay
Out-of-network: 50% coinsurance

Outpatient group therapy visit

In-network: $25 copay
Out-of-network: 50% coinsurance

Outpatient individual therapy visit

In-network: $25 copay
Out-of-network: 50% coinsurance

Opioid treatment services

Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)

In-network: 20% coinsurance per item
Out-of-network: 50% coinsurance per item

Prosthetics (like braces, artificial limbs)

In-network: 0-20% coinsurance per item
Out-of-network: 50% coinsurance per item

Diabetes supplies

In-network: $0 copay
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

Chemotherapy drugs

In-network: 20% coinsurance
Out-of-network: 50% coinsurance

Other Part B drugs

In-network: 20% coinsurance
Out-of-network: 50% coinsurance

Extra Benefits

Hearing

Hearing exam

In-network: $35 copay
Out-of-network: 50% coinsurance

Fitting/evaluation

In-network: $0 copay
Out-of-network: $0 copay

Hearing aids - All types

In-network: $699-999 copay
Out-of-network: $699-999 copay

Preventive Dental

Oral exam

Not covered

Cleaning

Not covered

Fluoride treatment

Not covered

Dental x-rays

Not covered

Comprehensive dental

Non-routine services

Not covered

Diagnostic services

Not covered

Restorative services

Not covered

Endodontics

Not covered

Periodontics

Not covered

Extractions

Not covered

Prosthodontics, other oral/maxillofacial surgery, other services

Not covered

Vision

Routine eye exam

In-network: $35 copay
Out-of-network: $35 copay or 50% coinsurance

Contact lenses

In-network: $0 copay
Out-of-network: $0 copay

Eyeglasses (frames & lenses)

In-network: $0 copay
Out-of-network: $0 copay

Eyeglass frames (only)

In-network: $0 copay
Out-of-network: $0 copay

Eyeglass lenses (only)

In-network: $0 copay
Out-of-network: $0 copay

Upgrades

Not covered

Other benefits

Fitness benefit

Limited coverage

Over the counter drug benefits

Limited coverage

In-home support services

Not covered

Home and bathroom safety devices

Not covered

Meals for short duration

Limited coverage

Annual physical exams

Limited coverage

Telehealth

Limited coverage

Summary rating of health plan quality

3.5

Staying healthy: screenings, tests, & vaccines

Managing chronic (long term) conditions

Member experience with health plan

Member complaints & changes in the health plan's performance

Health plan customer service

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