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PacificSource Medicare MyCare Choice Rx 24 (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for PacificSource Medicare MyCare Choice Rx 24 (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 MyCare Choice Rx 24 (HMO-POS) in 2025, please refer to our full plan details page.
PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) is a HMO-POS plan offered by PacificSource available for enrollment in 2025 to people living in Select Idaho Counties. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that PacificSource Medicare MyCare Choice Rx 24 (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 MyCare Choice Rx 24 (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 MyCare Choice Rx 24 (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $39.00. 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 MyCare Choice Rx 24 (HMO-POS) plan has a $199.00 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, preferred generic drugs have a $12.00 copay at a preferred pharmacy and a $17.00 copay at a standard pharmacy. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase where you will pay nothing for your Part D covered drugs.
Additional Benefits
The PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) plan offers a range of benefits with varying cost-sharing. You'll find no copay for many services, including primary care visits, home health services, and routine eye exams. The plan also includes copays for services like inpatient hospital stays, outpatient services, and specialist visits. Additional benefits include coverage for hearing aids, dental services, and medical equipment with coinsurance requirements.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you pay a $425 copay for days 1-7 and no copay for days 8-90, while Additional Days for Inpatient Hospital-Acute has no copay. Inpatient Hospital Psychiatric has a $275 copay for days 1-6 and no copay for days 7-90, while Additional Days and Non-Medicare-covered stay for Inpatient Hospital Psychiatric are not covered. Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are also not covered.
Outpatient Services See details
Outpatient services include outpatient hospital services with a copay between $0 and $425, observation services with a $425 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with a $35 copay for both individual and group sessions. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) plan with a $35 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) plan. Both ground and air ambulance services have a $275 copay, with no coinsurance, while transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgent and Worldwide Emergency Services, are covered by the PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) plan. Emergency Services have a $120 copay, Urgent Services have a $55 copay, Worldwide Emergency Coverage has a $120 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $275 copay; there is no coinsurance for any of these services.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services with a copay of $0-$10, Chiropractic Services with a $20 copay, Occupational Therapy Services with a $25 copay, Physician Specialist Services with a copay of $0-$35, and Mental Health Specialty Services with a $20 copay for individual and group sessions. Physical Therapy and Speech-Language Pathology Services have a $25 copay, and Additional Telehealth benefits have a copay of $0-$35. Opioid Treatment Program Services have a $35 copay.
Preventive Services See details
The PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) plan covers various preventive services, including Medicare-covered services with no copay, annual physical exams, and other preventive services. Kidney Disease Education Services are covered with 20% coinsurance. Other services like Health Education, In-Home Safety Assessment, and others are not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $35 copay, and fitting/evaluation for hearing aids. Prescription hearing aids are covered with a copay between $599 and $999, while OTC hearing aids, and inner, outer, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision Services includes coverage for routine eye exams, other eye exam services, and eyewear. Routine eye exams are covered once per year, and other eye exam services are covered with no copay or coinsurance. Eyewear is covered with a combined maximum of $200 every two years, and includes coverage for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames with no copay or coinsurance. Upgrades are not covered.
Dental Services See details
The PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) plan covers Medicare Dental Services with a $35 copay and other dental services, including oral exams, dental x-rays, and other diagnostic and preventive services with no copay. Restorative, adjunctive general, endodontics, periodontics, prosthodontics, and oral surgery services are covered with a 50% coinsurance, while maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) plan. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment is covered by the PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) plan, including Durable Medical Equipment (DME) with 20% coinsurance and Prosthetic Devices with 0-20% coinsurance; however, 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
The PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) plan covers Diagnostic and Radiological Services. Diagnostic Procedures/Tests have a copay of $15 and a coinsurance of at most 20%, while Lab Services have a coinsurance of at most 20%. Diagnostic Radiological Services have a copay of up to $375, and Therapeutic Radiological Services have a coinsurance of at most 20%. Outpatient X-Ray Services are not covered.
Home Health Services See details
Home Health Services are covered by the PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) 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 not covered by the PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) plan. All sub-services including Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, and Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) plan. There is 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
The PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) plan covers acupuncture with a $25 copay for up to 12 treatments per year, and also covers over-the-counter (OTC) items up to $25 every three months. Other services like meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and others are not covered.
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