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PacificSource Medicare MyCare Choice Rx 34 (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for PacificSource Medicare MyCare Choice Rx 34 (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 34 (HMO-POS) in 2025, please refer to our full plan details page.
PacificSource Medicare MyCare Choice Rx 34 (HMO-POS) is a HMO-POS plan offered by PacificSource available for enrollment in 2025 to people living in Select Idaho, Oregon and 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 Rx 34 (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 34 (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 34 (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $10.00. 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 34 (HMO-POS) plan has a $199 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, preferred generic drugs have a $6 copay at preferred pharmacies, while preferred brand drugs have a 31% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The PacificSource Medicare MyCare Choice Rx 34 (HMO-POS) plan offers coverage for a wide array of services. Inpatient hospital stays have copays between $0 and $315 depending on the type and length of stay, while outpatient services have copays ranging from $0 to $315. Other services include coverage for ambulance, emergency, and primary care visits with varying copays, along with vision and dental coverage. This plan also includes benefits such as home health services with no copay, hearing exams with a $40 copay, and prescription hearing aids with copays between $599 and $999. Additionally, there is coverage for medical equipment with coinsurance requirements, and skilled nursing facility stays with copays depending on the length of stay. The plan also covers acupuncture, and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $315 copay for days 1-7, and no copay for days 8-90; for Inpatient Hospital Psychiatric, you pay a $245 copay for days 1-7, and no copay for days 8-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and Additional Days and Non-Medicare-covered stays 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 $315, observation services with a $315 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with a $40 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 34 (HMO-POS) plan, with a copay of $35.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the PacificSource Medicare MyCare Choice Rx 34 (HMO-POS) plan. Ground and Air Ambulance Services have a $300 copay, and there is 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 the PacificSource Medicare MyCare Choice Rx 34 (HMO-POS) plan. Emergency Services have a $120 copay, Urgently Needed 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 $300 copay.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Chiropractic Services have a $20 copay, while Routine Chiropractic Care has a $25 copay for up to 12 visits per year. Occupational Therapy Services and Physical Therapy/Speech-Language Pathology Services have a $5 copay. Individual and Group Sessions for Mental Health and Psychiatric Services have a $30 copay, and Opioid Treatment Program Services have a $40 copay. Physician Specialist Services have a copay between $0 and $25, and Additional Telehealth Benefits have a copay between $0 and $30. Podiatry Services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams, and additional preventive services, with specific services such as Health Education, In-Home Safety Assessment, and others not covered. Alternative Therapies have a $25 copay per visit, and Kidney Disease Education Services have a 20% coinsurance.
Hearing Services See details
Hearing exams are covered with a $40 copay, and routine hearing exams are limited to one visit per year. Prescription hearing aids are covered with a copay between $599 and $999 for all types of hearing aids, but specific types of hearing aids like inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are also not covered.
Vision Services See details
The PacificSource Medicare MyCare Choice Rx 34 (HMO-POS) plan covers vision services, including routine eye exams once per year, and other eye exam services such as for glaucoma and diabetic retinopathy. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames are also covered, with a combined maximum benefit of $200 every two years, but upgrades are not covered.
Dental Services See details
Dental services are covered, with a $40 copay for Medicare Dental Services. Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable), Implant Services, Prosthodontics (fixed), and Oral and Maxillofacial Surgery are covered with 50% coinsurance.
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%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the PacificSource Medicare MyCare Choice Rx 34 (HMO-POS) plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical equipment is covered by the PacificSource Medicare MyCare Choice Rx 34 (HMO-POS) plan, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment. Durable medical equipment has a 20% coinsurance and requires authorization. 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 prior authorization required. Diagnostic Procedures/Tests have a coinsurance of at most 20% and a copayment of $15, while Lab Services have a coinsurance of at most 20%. Diagnostic Radiological Services have a copay of up to $390, 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 34 (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 covered, but 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. There is a copay for some services, but the specific amount is not detailed.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the PacificSource Medicare MyCare Choice Rx 34 (HMO-POS) plan. There is 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
Under Other Services, this plan covers acupuncture with a $25 copay, and up to 12 treatments per year. Over-the-counter (OTC) items are covered with a maximum benefit of $25 every three months. Annual Wellness Visits are covered, while meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management, Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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