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PacificSource Medicare MyCare Rx 40 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for PacificSource Medicare MyCare Rx 40 (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on PacificSource Medicare MyCare Rx 40 (HMO) in 2025, please refer to our full plan details page.
PacificSource Medicare MyCare Rx 40 (HMO) is a HMO plan offered by PacificSource available for enrollment in 2025 to people living in Select 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 Rx 40 (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 MyCare Rx 40 (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 MyCare Rx 40 (HMO), 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.
This plan has a $150.00 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 $5800.00 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 MyCare Rx 40 (HMO) plan has a $150 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For preferred generic drugs, you will pay a $9 copay at a preferred pharmacy or $17 at a standard pharmacy. For preferred brand drugs, you will pay 31% coinsurance at a preferred pharmacy or 33% at a standard pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The PacificSource Medicare MyCare Rx 40 (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services have a copay between $0 and $395. Emergency services have a copay, and ambulance services have a $325 copay. This plan includes coverage for primary care, preventive, hearing, vision, and dental services, each with different copays or coinsurance. Additional benefits include home health services with no copay, and coverage for medical equipment and diagnostic services with coinsurance. Other services such as acupuncture and over-the-counter items are also covered.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care. For acute inpatient hospital stays, you will pay a $395 copay for days 1-7, and no copay for days 8-90; there is no coinsurance. For psychiatric inpatient hospital stays, you will pay a $330 copay for days 1-5, and no copay for days 6-90; there is no coinsurance. Additional days and non-Medicare-covered stays for psychiatric care are not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a copay between $0-$395, observation services with a $395 copay, ambulatory surgical center services with no copay, individual and group outpatient substance abuse sessions with a $35 copay, and outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the plan and has a copay of $35.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the PacificSource Medicare MyCare Rx 40 (HMO) plan. Both ground and air ambulance services have a $325 copay, and there is no coinsurance; however, transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including urgently needed services and worldwide emergency services, are covered by the PacificSource Medicare MyCare Rx 40 (HMO) 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 $325 copay; all have no coinsurance.
Primary Care See details
The PacificSource Medicare MyCare Rx 40 (HMO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $5 copay, physician specialist services with a copay between $0 and $30, and mental health specialty services with a $35 copay for individual and group sessions. This plan also covers other health care professional services with a copay between $0 and $30, psychiatric services with a $35 copay for individual and group sessions, physical therapy and speech-language pathology services with a $5 copay, additional telehealth benefits with a copay between $0 and $35, and opioid treatment program services with a $35 copay. Podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, an annual physical exam, and additional services. Additional services may include a copay for alternative therapies. Kidney Disease Education Services are covered with 20% coinsurance, and other preventive services such as Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are covered. However, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $35 copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $599 and $999, 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 with one visit allowed every year, and other eye exam services. Eyewear benefits include coverage for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames with a combined maximum benefit of $200 every two years, but upgrades are not covered.
Dental Services See details
Dental services include coverage for Medicare dental services with a $35 copay, other dental services, oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services with 50% coinsurance, adjunctive general services with 50% coinsurance, endodontics with 50% coinsurance, periodontics with 50% coinsurance, removable prosthodontics with 50% coinsurance, implant services with 50% coinsurance, fixed prosthodontics with 50% coinsurance, and oral and maxillofacial surgery with 50% coinsurance; however, maxillofacial prosthetics and orthodontics are not covered. This plan has a maximum benefit of $1750 per year for other dental services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay with 0-20% coinsurance. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the PacificSource Medicare MyCare Rx 40 (HMO) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with a 20% coinsurance, and Diabetic Equipment with a 20% coinsurance for Diabetic Supplies and Therapeutic Shoes/Inserts. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests and Lab Services have a coinsurance of at most 20%, while Diagnostic Radiological Services have a copay of at most $320 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 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 specific services including Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are not covered. There is a copay for these services, but the amount is not specified in the provided information.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the PacificSource Medicare MyCare Rx 40 (HMO) plan. There is no copay for days 1-20, but there is a $203 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include acupuncture with a $25 copay, and up to 24 treatments per year. Over-the-counter (OTC) items are covered, with a maximum benefit of $25 every three months.
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