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PacificSource Medicare MyCare Choice 30 (HMO-POS)

Oregon Medicare Advantage Plan (2025 Plan)

Monthly Premium

Your Cost
$0
by PacificSource Medicare

Additional Coverage

HearingVisionDental

Overall Government Star Rating

 3.5
out of 5 stars

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Plan Overview

Plan Name
PacificSource Medicare MyCare Choice 30 (HMO-POS)
Insurance Carrier
PacificSource Medicare
Plan Type
Medicare Advantage Plan Without Prescription Drugs
Network Type
HMO

PacificSource Medicare MyCare Choice 30 (HMO-POS) is a Medicare Advantage Plan Without Prescription Drugs, which is available in Oregon and offered by the health insurance company PacificSource Medicare. This plan’s network type is HMO which determines in-network doctors who accept the health plan and whether a referral is needed.

Cost Summary

Monthly Premium
$0
Annual Deductible
$0
Max Out-of-Pocket
$4,200
Primary doctor visit
$0 copay
Specialist visit
$0 copay
ER visit
$120 copay per visit (always covered)
Ambulance
$300 copay

PacificSource Medicare MyCare Choice 30 (HMO-POS) has a monthly premium cost of $0 per month, with an annual deductible of $0 and a maximum out of pocket cost sharing of $8,950 In and Out-of-network $4,200 In-network. The most common benefit costs which people evaluate when choosing a plan are costs for a primary doctor visit, specialist doctor visit, emergency room visit, and ambulance. These costs are listed in this summary section and a full list of benefit costs for PacificSource Medicare MyCare Choice 30 (HMO-POS) are defined below.

Additional Benefits and Coverage

No
Part D Prescription Drug Coverage
Yes
Dental
Yes
Vision
Yes
Hearing

PacificSource Medicare MyCare Choice 30 (HMO-POS) is a Medicare Advantage plan which does not include Medicare Part D Prescription Drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. PacificSource Medicare MyCare Choice 30 (HMO-POS) includes coverage for hearing, vision, dental.

Medicare Advantage health plans can offer even more additional benefits. PacificSource Medicare MyCare Choice 30 (HMO-POS) includes coverage for the following additional benefits:

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
Not covered
Annual physical exams
Limited coverage
Telehealth
Limited coverage

Comparing the Quality Score of PacificSource Medicare MyCare Choice 30 (HMO-POS) to Other Plans in Oregon

Each year the federal government evaluates the quality of Medicare Advantage and Part D Prescription Drug plans based on a 5-star scoring system. For 2025, PacificSource Medicare MyCare Choice 30 (HMO-POS) received an overall government quality rating of 3.5 stars out of 5 stars.

PacificSource Medicare MyCare Choice 30 (HMO-POS) performed the same as Oregon’s State average overall quality score of 3.5 stars.

This Plan’s 5-star Gov’t Quality Score
Oregon State Average Score
Overall Government 5 Star Quality Rating
 3.5
 3.5
Summary rating of health plan quality
 3.5
 3.4
Staying healthy: screenings, tests, & vaccines
 4
 3.7
Managing chronic (long term) conditions
 3
 3.2
Member experience with health plan
 3
 2.8
Member complaints & changes in the health plan's performance
 4
 4.0
Health plan customer service
 3
 3.8

The government calculates an “Overall star rating” based on ratings for sub components including “Health plan star rating” and “Drug plan star rating”, which includes further subcomponents of each.

PacificSource Medicare MyCare Choice 30 (HMO-POS) received 3.5 stars for its health plan quality score which is better than the Oregon State average health plan quality score of 3.4 stars.

Plan Benefits and Coverage Details

Monthly Premium
$0
Health Portion of Premium
$0
Drug Portion of Premium
$0
Health Plan Deductible
$0
Health Plan Max Out-of-Pocket
$8,950 In and Out-of-network
$4,200 In-network
Nationwide Coverage included
No
Hearing Coverage included
Yes
Vision Coverage included
Yes
Dental Coverage included
Yes
Doctor Lookup Link
https://medicare.pacificsource.com/Search/Provider
Plan Link
http://www.Medicare.PacificSource.com

Medical Benefits

Doctor Services

Primary doctor visit
In-network: $0 copay
Out-of-network: $45 copay or 30% coinsurance per visit
Specialist visit
In-network: $0 copay
Out-of-network: $45 copay or 30% coinsurance per visit

Tests, labs, & imaging

Diagnostic tests & procedures
In-network: $20 copay or 20% coinsurance
Out-of-network: 30% coinsurance
Lab services
In-network: 0-20% coinsurance
Out-of-network: 30% coinsurance
Diagnostic radiology services (like MRI)
In-network: $0-310 copay
Out-of-network: 30% coinsurance
Outpatient x-rays
In-network: $0-15 copay
Out-of-network: 30% coinsurance
Emergency care
$120 copay per visit (always covered)
Urgent care
$55 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage
In-network: $425 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-network: 30% per stay
Outpatient hospital coverage
In-network: $0-250 copay per visit
Out-of-network: 30% coinsurance per visit

Skilled nursing facility

Skilled nursing facility
In-network: $0 per day for days 1 through 20
$203 per day for days 21 through 100
Out-of-network: 30% per stay

Preventive services

Preventive services
In-network: $0 copay
Out-of-network: 30% coinsurance

Ambulance

Ground ambulance
In-network: $300 copay
Out-of-network: $300 copay

Therapy services

Occupational therapy visit
In-network: $0 copay
Out-of-network: $45 copay or 30% coinsurance
Physical therapy & speech & language therapy visit
In-network: $0 copay
Out-of-network: $45 copay or 30% coinsurance

Mental health services

Outpatient group therapy with a psychiatrist
In-network: $0 copay
Out-of-network: 30% coinsurance
Outpatient individual therapy with a psychiatrist
In-network: $0 copay
Out-of-network: 30% coinsurance
Outpatient group therapy visit
In-network: $0 copay
Out-of-network: 30% coinsurance
Outpatient individual therapy visit
In-network: $0 copay
Out-of-network: 30% coinsurance

Opioid treatment services

Opioid treatment services
Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)
In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
Prosthetics (like braces, artificial limbs)
In-network: 0-20% coinsurance per item
Out-of-network: 30% coinsurance per item
Diabetes supplies
In-network: 20% coinsurance per item
Out-of-network: 30% 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: 0-20% coinsurance
Out-of-network: $35 copay or 30% coinsurance
Other Part B drugs
In-network: 0-20% coinsurance
Out-of-network: $35 copay or 30% coinsurance

Extra Benefits

Hearing

Hearing exam
In-network: $30 copay
Out-of-network: 30% coinsurance
Fitting/evaluation
In-network: $0 copay
Out-of-network: $0 copay
Hearing aids - All types
In-network: $599-999 copay
Out-of-network: $599-999 copay

Preventive Dental

Oral exam
In-network: $0 copay
Out-of-network: $0 copay
Cleaning
In-network: $0 copay
Out-of-network: $0 copay
Fluoride treatment
In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays
In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Restorative services
In-network: $0 copay
Out-of-network: $0 copay
Endodontics
In-network: $0 copay
Out-of-network: $0 copay
Periodontics
In-network: $0 copay
Out-of-network: $0 copay
Prosthodontics, removable
In-network: $0 copay
Out-of-network: $0 copay
Prosthodontics, fixed
In-network: $0 copay
Out-of-network: $0 copay
Maxillofacial prosthetics
Not covered
Implant services
In-network: $0 copay
Out-of-network: $0 copay
Oral and maxillofacial surgery
In-network: $0 copay
Out-of-network: $0 copay
Orthodontics
Not covered
Adjunctive general services
In-network: $0 copay
Out-of-network: $0 copay

Vision

Routine eye exam
In-network: $0 copay
Out-of-network: 30% 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

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