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PacificSource Medicare MyCare Choice 30 (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for PacificSource Medicare MyCare Choice 30 (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 30 (HMO-POS) in 2025, please refer to our full plan details page.
PacificSource Medicare MyCare Choice 30 (HMO-POS) is a HMO-POS plan offered by PacificSource available for enrollment in 2025 to people living in Select Idaho, Montana, Oregon, Washington 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 30 (HMO-POS) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about PacificSource Medicare MyCare Choice 30 (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 30 (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
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
Prescription drugs are not covered by PacificSource Medicare MyCare Choice 30 (HMO-POS).
Additional Benefits
The PacificSource Medicare MyCare Choice 30 (HMO-POS) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have copays, while outpatient services have copays that vary. Emergency services have a copay, as well as ambulance services. This plan covers primary care, preventive, hearing, vision, and dental services. Vision services include routine eye exams with no copay, and dental services have a copay. The plan also covers home infusion, dialysis, medical equipment, diagnostic and radiological services, home health, skilled nursing, and other services.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $425 copay for days 1-5, and no copay for days 6-90; Inpatient Hospital Psychiatric services have a $420 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services are covered by the PacificSource Medicare MyCare Choice 30 (HMO-POS) plan, with copays ranging from $0 to $250 for Outpatient Hospital Services, and a $250 copay for Observation Services. Ambulatory Surgical Center (ASC) Services have no copay, while Individual and Group Sessions for Outpatient Substance Abuse, and Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under this plan, with a $55 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the PacificSource Medicare MyCare Choice 30 (HMO-POS) plan. Ground and Air Ambulance Services each have a $300 copay, with no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services, are covered by the PacificSource Medicare MyCare Choice 30 (HMO-POS) plan. Emergency Services have a $120 copay, while Urgently Needed Services have a $55 copay, and 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
The PacificSource Medicare MyCare Choice 30 (HMO-POS) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Routine chiropractic care is covered for up to 24 visits per year, and individual and group sessions for mental health and psychiatric services are not covered.
Preventive Services See details
Preventive services include coverage for annual physical exams, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. Kidney disease education services have a 20% coinsurance, and alternative therapies, and fitness benefits are covered. However, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and other services are not covered.
Hearing Services See details
Hearing services with the PacificSource Medicare MyCare Choice 30 (HMO-POS) plan include hearing exams with a $30 copay, and prescription hearing aids with a copay between $599 and $999. Routine hearing exams and fitting/evaluation for hearing aids are covered, 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 routine eye exams once per year, with no copay. This plan also covers other eye exam services, contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames; however, upgrades are not covered. Eyewear has a combined maximum plan benefit coverage of $250 per year.
Dental Services See details
Under the PacificSource Medicare MyCare Choice 30 (HMO-POS) plan, dental services are covered, with a $30 copay for Medicare Dental Services. Other Dental Services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable), implant services, prosthodontics (fixed), and oral and maxillofacial surgery, all of which are covered. Maxillofacial Prosthetics and Orthodontics are not covered. The plan has a maximum benefit of $2,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the PacificSource Medicare MyCare Choice 30 (HMO-POS) plan. This includes Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the PacificSource Medicare MyCare Choice 30 (HMO-POS) plan. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment is covered by PacificSource Medicare MyCare Choice 30 (HMO-POS), including Durable Medical Equipment with 20% coinsurance and Prosthetic Devices with 0-20% coinsurance. Medical Supplies have 20% coinsurance, and Diabetic Equipment is covered with coinsurance, including Diabetic Supplies and Therapeutic Shoes/Inserts, both with 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic services and radiological services, are covered. Diagnostic Procedures/Tests and Lab Services have a coinsurance of up to 20%, while Diagnostic Radiological Services have a copay of up to $310, and Outpatient X-Ray Services have no copay. Therapeutic Radiological Services have a coinsurance of up to 20%.
Home Health Services See details
Home Health Services are covered by the PacificSource Medicare MyCare Choice 30 (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 30 (HMO-POS) plan. 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 under the PacificSource Medicare MyCare Choice 30 (HMO-POS) plan. You will have no copay for days 1-20, and a $203 copay for days 21-100.
Other Services See details
Other Services includes acupuncture, over-the-counter items, and annual wellness visits. Acupuncture is covered for up to 24 treatments per year. Over-the-counter items are covered with a maximum benefit of $100 every three months, and annual wellness visits are also covered. Other services such as meals, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and Private Duty Nursing Services are not covered.
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