PacificSource Medicare Essentials 2 (HMO)


Medicare Plan Details

2021 Plan
Monthly Premium
(select county for price)

 

by PacificSource Medicare
Additional Coverage
Hearing Vision
Overall Government Star Rating
 4.0
out of 5 stars

State: Oregon

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

 

$0
$0
$0
$0
$5,500 In-network
No
Yes
Yes
No

Medical Benefits

Doctor Services

$0-10 copay per visit
$0-40 copay per visit

Tests, labs, & imaging

$15 copay or 20% coinsurance
$0-15 copay or 20% coinsurance
$190-310 copay
$0-15 copay
$90 copay per visit (always covered)
$40 copay per visit (always covered)

Hospital Services

$325 per day for days 1 through 5
$0 per day for days 6 through 90
$0-325 copay per visit

Skilled nursing facility

$0 per day for days 1 through 20
$184 per day for days 21 through 100

Preventive services

$0 copay

Ambulance

$300 copay

Therapy services

$35 copay
$35 copay

Mental health services

$25 copay
$25 copay
$25 copay
$25 copay

Opioid treatment services

Covered

Other services

20% coinsurance per item
0-20% coinsurance per item
$0 copay

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

Part B Drugs

20% coinsurance
20% coinsurance

Extra Benefits

Hearing

$40 copay
$0 copay
$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

$40 copay
$0 copay
$0 copay
$0 copay
$0 copay
Not covered

Other benefits

Limited coverage
Limited coverage
Not covered
Not covered
Limited coverage
Limited coverage
Limited coverage
 4
 4
 4
 4
 4
 4

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