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PacificSource Medicare Essentials Choice Rx 14 (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for PacificSource Medicare Essentials Choice Rx 14 (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) in 2025, please refer to our full plan details page.
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) is a HMO-POS 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 Choice Rx 14 (HMO-POS) 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 Choice Rx 14 (HMO-POS).
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 Choice Rx 14 (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $93.00. 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 a $199.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $8950.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $8950.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 Choice Rx 14 (HMO-POS) plan has a $199 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy type. For generic drugs, you can expect to pay between $12 and $47. For preferred brand drugs, you'll pay 31% to 33% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services with varying copays, and emergency services with copays. Primary care, including specialist visits, mental health, and physical therapy, is covered with copays. Preventive services have no copay, and vision and dental services are covered with annual maximums. Additional benefits include coverage for hearing exams and hearing aids, ambulance services, home health services with no copay, and skilled nursing facility stays. The plan also covers home infusion services, dialysis services, durable medical equipment, and diagnostic and radiological services. Other services include acupuncture and over-the-counter items, all with copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute with a $375 copay for days 1-7, and no copay for days 8-90, and Inpatient Hospital Psychiatric with a $275 copay for days 1-6, and no copay for days 7-90. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a copay between $0 and $375, observation services with a $375 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with a copay of $35. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) plan, with a copay of $35.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) plan. Both ground and air ambulance services have a $300 copay, with no coinsurance, while 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 has a $120 copay, Urgently Needed Services has a $55 copay, Worldwide Emergency Coverage has a $120 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $300 copay.
Primary Care See details
Primary Care Physician Services have a copay between $0 and $10. Chiropractic Services have a $20 copay, and routine chiropractic care has a $25 copay for up to 12 visits per year. Occupational Therapy Services have a $35 copay. Physician Specialist Services have a copay between $0 and $35. Mental Health Specialty Services, Individual Sessions for Mental Health Specialty Services, and Group Sessions for Mental Health Specialty Services each have a $30 copay. Other Health Care Professional services have a copay between $10 and $35. Psychiatric Services, Individual Sessions for Psychiatric Services, and Group Sessions for Psychiatric Services each have a $30 copay. Physical Therapy and Speech-Language Pathology Services have a $35 copay. Additional Telehealth Benefits have a copay between $0 and $35. Opioid Treatment Program Services have a $35 copay. Podiatry Services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with no copay, annual physical exams, and additional preventive services. Additional preventive services may have a copay, and alternative therapies have a $25 copay per visit for up to 12 visits. Kidney Disease Education Services have a 20% coinsurance. Other preventive services are covered, including Glaucoma Screenings, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKGs following a Welcome Visit.
Hearing Services See details
Hearing Services include routine hearing exams with a $35 copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a copay between $599 and $999, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams and eyewear. Routine eye exams are covered once per year, and other eye exam services are covered. Eyewear has a combined maximum benefit of $200 every two years, and includes coverage for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames; upgrades are not covered.
Dental Services See details
Dental services are covered, with a $1,500 annual maximum benefit. Medicare dental services have a $35 copay, while other services, including restorative, adjunctive general, endodontics, periodontics, prosthodontics (removable and fixed), implant services, and oral and maxillofacial surgery, have a 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 and coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) plan. The coinsurance for these services is 20%.
Medical Equipment See details
Medical equipment coverage under the PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) plan includes Durable Medical Equipment (DME) with 20% coinsurance and Prosthetic Devices with 0-20% coinsurance, but Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. Medical Supplies have 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures/tests with a minimum 20% coinsurance and a $15 copay, lab services with no copay and a minimum 20% coinsurance, and therapeutic radiological services with a minimum 20% coinsurance. Diagnostic radiological services have a copay of up to $340, and outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered 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 not covered by the PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under this plan. For days 1-20, there is no copay, and for days 21-100, the copay is $203. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include acupuncture with a $25 copay per visit, with a limit of 12 treatments per year, and over-the-counter (OTC) items with a maximum benefit of $25 every three months. Other services such as meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and others are not covered.
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