PacificSource Dual Care (HMO D-SNP)

Medicare Plan Details (2023 Plan)


Monthly Premium

 

by PacificSource Medicare
Additional Coverage
HearingVision
Overall Government Star Rating
 3.5
out of 5 stars

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Plan Type

Medicare Advantage (Part C) with Prescription Drug (Part D)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D

 

$0
$0
$0
$0
$8,300 In-network
No
Yes
Yes
No

Doctor Services

$0 copay
$0 copay

Tests, labs, & imaging

$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay

Hospital Services

$0 copay
$0 copay

Skilled nursing facility

$0 copay

Preventive services

$0 copay

Ambulance

$0 copay

Therapy services

$0 copay
$0 copay

Mental health services

$0 copay
$0 copay
$0 copay
$0 copay

Opioid treatment services

Covered

Other services

$0 copay
$0 copay
$0 copay

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

TiersInitial coverage phaseGap coverage phase1Catastrophic coverage phase
Preferred Generic$0.00 copay


Generic drugs :
$4.15 copay or 5% (whichever costs more)

Brand-name drugs :
$10.35 copay or 5% (whichever costs more)

Generic$20.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug34%
Specialty Tier25%
1 For all other drugs, you pay 25% for generic drugs and 25% for brand-name drugs.

Part B Drugs

$0 copay
$0 copay

Hearing

$0 copay
Not covered
Not covered
Not covered
Not covered

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

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

Other benefits

Limited coverage
Limited coverage
Not covered
Not covered
Limited coverage
Not covered
Limited coverage
 4
 4
 3
 4
 4
 4
 3.5
 3
 4
 3
 3

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