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PacificSource Medicare Essentials Rx 27 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for PacificSource Medicare Essentials Rx 27 (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 27 (HMO) in 2025, please refer to our full plan details page.
PacificSource Medicare Essentials Rx 27 (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 27 (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 27 (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 27 (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $43.00. 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 $399.00 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 Maximum Out-Of-Pocket cost of $6200.00 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 27 (HMO) plan has a $399.00 deductible for prescription drugs. After you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, you will pay a $12.00 copay for preferred generic drugs at a preferred pharmacy. The plan also offers an enhanced alternative drug benefit.
Additional Benefits
The PacificSource Medicare Essentials Rx 27 (HMO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services with copays, and partial hospitalization with a $55 copay. Emergency and urgent care services are covered, with copays varying depending on the type of service and location. This plan also covers primary care visits, chiropractic services, and various therapies with copays, along with preventive services like annual exams. Vision and dental services are included, featuring no copays for certain services and coinsurance for others. The plan covers home health services with no copay, and skilled nursing facility stays with a copay after the first 20 days.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you have a $395 copay for days 1-7, and no copay for days 8-90; for Inpatient Hospital Psychiatric, you have a $395 copay for days 1-4, and no copay for days 5-90.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $395, observation services with a $395 copay, and ambulatory surgical center services with no copay. Individual and group sessions for outpatient substance abuse have a copay of $40.00. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial hospitalization is covered under the PacificSource Medicare Essentials Rx 27 (HMO) plan. You will have a $55 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the PacificSource Medicare Essentials Rx 27 (HMO) plan. Ground and Air Ambulance Services have a $325 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 by this plan. 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 $325 copay.
Primary Care See details
The PacificSource Medicare Essentials Rx 27 (HMO) plan covers primary care physician services and chiropractic services with copays ranging from $0 to $19 and $20, respectively. Occupational therapy services have a $40 copay, and physical therapy and speech-language pathology services have a $40 copay. Physician specialist services have a copay between $0 and $39. Mental health specialty services, psychiatric services, and opioid treatment program services have a $40 copay, while additional telehealth benefits have a copay between $0 and $40. Routine chiropractic care has a $25 copay for up to 12 visits per year. Podiatry services are not covered.
Preventive Services See details
The PacificSource Medicare Essentials Rx 27 (HMO) plan covers a variety of preventive services, including annual physical exams, glaucoma screenings, and diabetes self-management training. Alternative therapies have a $25 copay per visit for up to 12 visits, and kidney disease education services have a 20% coinsurance.
Hearing Services See details
Hearing Services include routine hearing exams with a $50 copay, and fitting/evaluation for hearing aids, and prescription hearing aids with a copay between $599 and $999, while prescription hearing aids - inner ear, outer ear, and over the ear, and OTC hearing aids are not covered. Routine hearing exams and prescription hearing aids (all types) are limited to 1 and 2 visits per year, respectively.
Vision Services See details
The PacificSource Medicare Essentials Rx 27 (HMO) plan covers vision services, including routine eye exams once every two years, and other eye exam services. Eyewear is covered with a combined maximum of $200 every two years, and contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are covered, but upgrades are not covered.
Dental Services See details
The PacificSource Medicare Essentials Rx 27 (HMO) plan covers dental services, including oral exams, dental x-rays, and other diagnostic and preventive services with no copay. Restorative, adjunctive, endodontic, periodontic, prosthodontic, implant, and oral surgery services are covered with 50% coinsurance. Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. You will have a $35 copay for Medicare Part B Insulin Drugs, and coinsurance between 0% and 20% for Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs.
Dialysis Services See details
Dialysis Services are covered by the PacificSource Medicare Essentials Rx 27 (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered by the PacificSource Medicare Essentials Rx 27 (HMO) plan, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment. Durable medical equipment has a 20% coinsurance and requires authorization, while durable medical equipment for use outside the home is not covered. Prosthetic devices have a 0-20% coinsurance, and medical supplies have a 20% coinsurance. Diabetic supplies and therapeutic shoes/inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with a 20% coinsurance for Diagnostic Procedures/Tests, and a $0 copay and 20% coinsurance for Lab Services. Diagnostic Radiological Services have a copay of up to $375.00, and Therapeutic Radiological Services have a 20% coinsurance. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the PacificSource Medicare Essentials Rx 27 (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, but the plan does not cover any of the sub-services. The plan has a copay for Cardiac and Pulmonary Rehabilitation Services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the PacificSource Medicare Essentials Rx 27 (HMO) plan, with no copay for days 1-20 and a $203 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The PacificSource Medicare Essentials Rx 27 (HMO) plan covers acupuncture with a $25 copay, up to 12 treatments per year. Over-the-counter items are covered, with a maximum benefit of $20 every three months. Other services like meals, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and more are not covered.
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