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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 2026, please refer to our full plan details page.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
PacificSource Medicare MyCare Rx 40 (HMO) is a HMO plan offered by Pacificsource Community Health Plans available for the 2026 plan year to people living in Select 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 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
Health deductible: information not available.
This plan has a $399.00 drug deductible that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6750.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $6750.00 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 features an annual prescription drug deductible of $399. For Tier 1 preferred generic drugs, members pay no copay for one- to three-month supplies through standard pharmacies and standard mail order. Tier 2 generic medications require a $6 copay for a one-month supply at standard pharmacies, while standard mail order offers a flat $6 copay for up to a three-month supply. For Tier 3 preferred brand drugs, the plan charges a 24% coinsurance at standard pharmacies and a lower 15% coinsurance through standard mail order. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 28% coinsurance, with Tier 5 coverage limited to a one-month supply. These cost-sharing tiers help you understand your out-of-pocket prescription costs under this PacificSource Medicare Advantage plan.
Additional Benefits
The PacificSource Medicare MyCare Rx 40 (HMO) plan offers comprehensive medical coverage featuring no copays for preventive services, annual physicals, and home health care. For primary care, doctor visits range from no copay to $20, while specialist visits cost from no copay to $30. Inpatient hospital stays require a $435 daily copay for days 1 through 7 of an acute stay with no copay for subsequent days, while emergency room visits carry a $120 copay. This plan also includes key supplemental benefits, such as routine vision and preventive dental care with no copays or coinsurance, including a $200 eyewear allowance and a $750 annual dental limit. Routine hearing exams are available for a $35 copay, and prescription hearing aids require a copay ranging from $599 to $999. Durable medical equipment, diabetic supplies, and dialysis services are covered with no copay and a 20% coinsurance.
Inpatient Hospital See details
PacificSource Medicare MyCare Rx 40 (HMO) covers inpatient hospital services with no coinsurance, requiring a $435 copay for days 1 to 7 of an acute stay and a $325 copay for days 1 to 7 of a psychiatric stay, with no copay for days 8 and beyond. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
PacificSource Medicare MyCare Rx 40 (HMO) covers outpatient services with no coinsurance, including ambulatory surgical center and outpatient blood services with no copay. Outpatient hospital services require a copay of $0 to $425, observation services cost a $425 copay per stay, and outpatient substance abuse sessions carry a $35 copay, all with no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by PacificSource Medicare MyCare Rx 40 (HMO) with a $35.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
PacificSource Medicare MyCare Rx 40 (HMO) covers ground and air ambulance services with a $325 copay and no coinsurance, though prior authorization is required. For transportation benefits, some services are covered but transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
PacificSource Medicare MyCare Rx 40 (HMO) covers emergency services with a $120 copay, waived if admitted to the hospital within 72 hours, and urgently needed services with a $50 copay, both with no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays of $120, $50, and $325, respectively.
Primary Care See details
PacificSource Medicare MyCare Rx 40 (HMO) partially covers primary care services with no coinsurance, featuring copays ranging from no copay to $20 for primary care visits and $0 to $30 for specialists. Therapy, mental health, and telehealth services are covered with copays up to $35, while podiatry and other chiropractic services are not covered.
Preventive Services See details
PacificSource Medicare MyCare Rx 40 (HMO) covers preventive services, including annual physical exams and screenings with no copay and no coinsurance, though kidney disease education requires a 20% coinsurance and no copay. Additional preventive benefits are only partially covered; alternative therapies (requiring a $25 copay and no coinsurance) and fitness benefits are included, but services such as health education, in-home safety assessments, and weight management are not covered.
Hearing Services See details
PacificSource Medicare MyCare Rx 40 (HMO) covers annual routine hearing exams with a $35 copay, no deductible, and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay of $599 to $999, though inner ear, outer ear, over the ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Vision services are partially covered by PacificSource Medicare MyCare Rx 40 (HMO) with no copay and no coinsurance, though eyewear upgrades are not covered. This benefit includes one routine eye exam per year and a $200 combined maximum allowance every two years for contacts and eyeglasses.
Dental Services See details
PacificSource Medicare MyCare Rx 40 (HMO) dental benefits are partially covered, providing preventive care with no copay and no coinsurance up to a $750 annual limit, and Medicare-covered dental services for a $35 copay and no coinsurance. Comprehensive dental services are covered with no copay and 50% coinsurance, while maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by PacificSource Medicare MyCare Rx 40 (HMO) with no copay, though prior authorization is required and step therapy may apply. Associated Medicare Part B chemotherapy and other drugs require 0% (no coinsurance) to 20% coinsurance, while Part B insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by the PacificSource Medicare MyCare Rx 40 (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
PacificSource Medicare MyCare Rx 40 (HMO) covers medical equipment, including durable medical equipment (DME), medical supplies, and diabetic equipment, with no copay and 20% coinsurance. Prosthetic devices are covered with no copay and coinsurance ranging from no coinsurance up to 20%, with prior authorization required for these services.
Diagnostic and Radiological Services See details
PacificSource Medicare MyCare Rx 40 (HMO) covers diagnostic and radiological services with prior authorization required. Lab services and diagnostic radiological services are offered with no copays and no coinsurance, while diagnostic procedures and therapeutic radiological services require a 20% coinsurance, and outpatient X-rays feature no copay but require coinsurance.
Home Health Services See details
Home health services are covered by PacificSource Medicare MyCare Rx 40 (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
PacificSource Medicare MyCare Rx 40 (HMO) covers some cardiac rehabilitation services with no coinsurance, though several sub-services are not covered in practice. Specifically, standard cardiac rehabilitation (with a $35 copay), intensive cardiac rehabilitation ($40 copay), pulmonary rehabilitation ($15 copay), and supervised exercise therapy for peripheral artery disease ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
PacificSource Medicare MyCare Rx 40 (HMO) 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
Other services are partially covered by PacificSource Medicare MyCare Rx 40 (HMO), featuring acupuncture with a $25 copay and no coinsurance for up to 12 treatments yearly, alongside annual wellness visits and over-the-counter items with no copay and no coinsurance. Meal benefits are not covered under this plan.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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