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PacificSource Medicare Essentials Rx 6 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for PacificSource Medicare Essentials Rx 6 (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on PacificSource Medicare Essentials Rx 6 (HMO) in 2025, please refer to our full plan details page.
PacificSource Medicare Essentials Rx 6 (HMO) is a HMO plan offered by PacificSource available for enrollment in 2025 to people living in Select Oregon Counties. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that PacificSource Medicare Essentials Rx 6 (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about PacificSource Medicare Essentials Rx 6 (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For PacificSource Medicare Essentials Rx 6 (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $209.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4950.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The PacificSource Medicare Essentials Rx 6 (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay or coinsurance for your prescriptions, depending on the drug tier and pharmacy. For example, preferred generic drugs have a $12 copay at a preferred pharmacy. Once your total drug costs reach $2,000, you enter the coverage gap. The plan also offers a Part D premium reduction for those who qualify for the low-income subsidy.
Additional Benefits
The PacificSource Medicare Essentials Rx 6 (HMO) plan offers a range of benefits with varying cost-sharing. It includes coverage for inpatient and outpatient hospital services, with copays ranging from $0 to $350, and also covers emergency, primary care, preventive, and hearing services. The plan also provides coverage for vision and dental services, with a $200 combined maximum benefit for eyewear every two years and a $500 maximum benefit for other dental services per year. This plan offers coverage for ambulance, home health, and skilled nursing facility services. The plan also covers services such as diagnostic and radiological services, along with medical equipment and dialysis services. Additionally, the plan offers benefits like acupuncture, home infusion, and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $350 copay for days 1-7, and no copay for days 8-90, while additional days are covered with no copay. For Inpatient Hospital Psychiatric, you pay a $275 copay for days 1-5, and no copay for days 6-90, but additional days are not covered. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and Non-Medicare-covered stays and additional days for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a copay between $0 and $275, observation services with a $275 copay, and ambulatory surgical center services with no copay. Individual and group sessions for outpatient substance abuse have a copay of $25, while outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered with a $30 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the PacificSource Medicare Essentials Rx 6 (HMO) plan, with a $150 copay for both ground and air ambulance services and no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $120 copay, and Urgently Needed Services have a $55 copay, while Worldwide Emergency Coverage has a $120 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $150 copay.
Primary Care See details
The PacificSource Medicare Essentials Rx 6 (HMO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy, physician specialist services with a $0-$15 copay, and mental health specialty services, including individual and group sessions with a $20 copay. The plan also covers other health care professionals with a $0-$25 copay, psychiatric services with a $20 copay for individual and group sessions, physical therapy, speech-language pathology services, additional telehealth benefits with a $0-$25 copay, and opioid treatment program services with a $25 copay. Podiatry services are not covered.
Preventive Services See details
The PacificSource Medicare Essentials Rx 6 (HMO) plan covers a variety of preventive services, including Medicare-covered services with no copay, annual physical exams, and additional preventive services. Additional Preventive Services include a copay for Alternative Therapies. Kidney Disease Education Services have a 20% coinsurance. Other preventive services include Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. However, Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered. The Fitness Benefit is covered, with Memory Fitness and Activity Tracker offered.
Hearing Services See details
Hearing exams are covered with a $25 copay, including routine hearing exams and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a copay between $599 and $999 for 2 per year, but inner ear, outer ear, and over the ear prescription hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams, other eye exam services, and eyewear. Routine eye exams are covered once every two years. Other eye exam services are unlimited. Eyewear has a combined maximum benefit of $200 every two years, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $25 copay and other dental services with a $500 maximum benefit per year, including oral exams, x-rays, other diagnostic services, cleanings, fluoride treatments, other preventive services, restorative services, adjunctive general services, endodontics, periodontics, removable prosthodontics, implant services, fixed prosthodontics, and oral and maxillofacial surgery, all with 50% coinsurance. Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. Medicare Part B Insulin Drugs have a $35 copay with 0-20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the PacificSource Medicare Essentials Rx 6 (HMO) plan. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment benefits are covered, including Durable Medical Equipment (DME) with a 20% coinsurance and no copay, and Prosthetics/Medical Supplies with a 20% coinsurance and no copay. Prosthetic Devices have a 0-20% coinsurance and no copay. Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures/tests with at most 20% coinsurance and a minimum copayment of $15, and lab services with no copay and at most 20% coinsurance. The plan also covers diagnostic radiological services with a copay of up to $250, therapeutic radiological services with at most 20% coinsurance, and outpatient X-ray services with no copay.
Home Health Services See details
Home Health Services are covered by the PacificSource Medicare Essentials Rx 6 (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the PacificSource Medicare Essentials Rx 6 (HMO) plan, but the plan does not specify the cost sharing details. However, the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the PacificSource Medicare Essentials Rx 6 (HMO) plan, with no copay for days 1-20, and a $203 copay for days 21-100. Additional days beyond Medicare-covered for SNF, and non-Medicare-covered stays for SNF, are not covered.
Other Services See details
Under the PacificSource Medicare Essentials Rx 6 (HMO) plan, acupuncture is covered with a $25 copay, and you are limited to 18 treatments per year. Over-the-counter items are covered, with a maximum benefit coverage amount of $25 every three months, and other services such as meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and others are not covered.
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