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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 2026, 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, and Oregon Counties. This plan received an overall rating of 3.5 out of 5 stars in 2026.
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:
Sign up for PacificSource Medicare MyCare Choice 30 (HMO-POS)
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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 comprehensive medical coverage with no copays or coinsurance for primary care, specialist visits, and home health services. Inpatient hospital stays feature no coinsurance, with a $425 daily copay for days one through five of acute care, while outpatient services range from no copay up to a $400 copay. Emergency room visits require a $120 copay, which is waived upon hospital admission, and urgent care is covered with a $50 copay. This plan also includes valuable supplemental benefits, such as vision care and preventive dental services up to a $1,000 annual limit with no copays or coinsurance. Routine hearing exams are available for a $30 copay, while skilled nursing facility stays require no copay for the first 20 days and a $203 daily copay for days 21 through 100. Additionally, members receive a $50 quarterly over-the-counter allowance and up to 24 alternative therapy visits with no copays or coinsurance.
Inpatient Hospital See details
Inpatient hospital services are partially covered by PacificSource Medicare MyCare Choice 30 (HMO-POS), featuring no coinsurance for all stays, a $425 copay for days 1 to 5 of acute care, and a $420 copay for days 1 to 5 of psychiatric care. Days 6 and beyond have no copay, though upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
PacificSource Medicare MyCare Choice 30 (HMO-POS) covers outpatient hospital services with a $0 to $400 copay and no coinsurance, observation services with a $400 copay per stay and no coinsurance, and ambulatory surgical center services with no copay and no coinsurance. Outpatient blood services have no copay or coinsurance, and while some outpatient substance abuse services are covered with no copay or coinsurance, individual and group sessions are not covered.
Partial Hospitalization See details
PacificSource Medicare MyCare Choice 30 (HMO-POS) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance services under the PacificSource Medicare MyCare Choice 30 (HMO-POS) require prior authorization and carry a $300 copay with no coinsurance for both ground and air transport. Transportation services to plan-approved or other health-related locations are not covered.
Emergency Services See details
PacificSource Medicare MyCare Choice 30 (HMO-POS) covers emergency services with a $120 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 72 hours. Urgently needed services are covered with a $50 copay and no coinsurance, while worldwide emergency services are available with no coinsurance and copays of $120 for emergency care, $50 for urgent care, and $300 for emergency transportation.
Primary Care See details
PacificSource Medicare MyCare Choice 30 (HMO-POS) covers primary care, specialist, therapy, telehealth, and opioid treatment services with no copay and no coinsurance, though prior authorization is required for some benefits. Chiropractic care is partially covered with no copay or coinsurance for up to 24 routine visits per year, while other chiropractic services, podiatry, mental health specialty, and psychiatric services are not covered.
Preventive Services See details
PacificSource Medicare MyCare Choice 30 (HMO-POS) provides partially covered preventive services with no copay and no coinsurance for annual physicals, screenings, fitness benefits, and up to 24 alternative therapy visits, while kidney disease education has no copay and a 20% coinsurance. Several supplemental services are not covered, including health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, weight management, therapeutic massage, adult day health, nutritional benefits, home-based palliative care, in-home support, caregiver support, smoking cessation, and counseling.
Hearing Services See details
PacificSource Medicare MyCare Choice 30 (HMO-POS) provides partially covered hearing services, featuring routine hearing exams for a $30 copay and no coinsurance. Up to two prescription hearing aids are covered per year with a copay ranging from $599 to $999 and no coinsurance, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
PacificSource Medicare MyCare Choice 30 (HMO-POS) partially covers vision services with no copay, no coinsurance, and no deductible, including one routine eye exam per year and exams for glaucoma and diabetic retinopathy. Eyewear, such as contacts, lenses, and frames, is also covered with no copay or coinsurance up to a $200 annual limit, but upgrades are not covered.
Dental Services See details
PacificSource Medicare MyCare Choice 30 (HMO-POS) partially covers dental services, offering Medicare-covered dental with a $30 copay and no coinsurance, and other preventive and comprehensive dental benefits up to a $1,000 annual limit with no copay and no coinsurance. Please note that maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
PacificSource Medicare MyCare Choice 30 (HMO-POS) covers Home Infusion bundled Services with no copay, subject to prior authorization. Under this benefit, Medicare Part B chemotherapy and other drugs require coinsurance ranging from no coinsurance to 20% coinsurance, while Part B insulin is covered with a $35 copay and coinsurance ranging from no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the PacificSource Medicare MyCare Choice 30 (HMO-POS) plan with no copay and a 20% coinsurance.
Medical Equipment See details
PacificSource Medicare MyCare Choice 30 (HMO-POS) covers medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, with no copay and a 20% coinsurance, though prosthetic devices range from no coinsurance to 20% coinsurance. Prior authorization is required for these benefits, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
PacificSource Medicare MyCare Choice 30 (HMO-POS) covers diagnostic and radiological services with prior authorization, offering diagnostic procedures for a $20 copay and 20% coinsurance, and lab services with no coinsurance. Outpatient X-rays and diagnostic radiological services are available with no copay, while therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by PacificSource Medicare MyCare Choice 30 (HMO-POS) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under PacificSource Medicare MyCare Choice 30 (HMO-POS) with no coinsurance, though only some services are covered in practice. Specifically, cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
PacificSource Medicare MyCare Choice 30 (HMO-POS) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20 and a $203 daily copay for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
PacificSource Medicare MyCare Choice 30 (HMO-POS) partially covers other services, offering acupuncture for up to 24 treatments per year and an annual wellness visit with no copay and no coinsurance. Over-the-counter (OTC) items are also covered with no copay and no coinsurance up to $50 every three months, though meal benefits are not covered.
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