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PacificSource Medicare Essentials Rx 41 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for PacificSource Medicare Essentials Rx 41 (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on PacificSource Medicare Essentials Rx 41 (HMO) in 2025, please refer to our full plan details page.
PacificSource Medicare Essentials Rx 41 (HMO) is a HMO plan offered by PacificSource available for enrollment in 2025 to people living in Lane County. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that PacificSource Medicare Essentials Rx 41 (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 Essentials Rx 41 (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 Essentials Rx 41 (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $89.00. 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 $299.00 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 $5950.00 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 Essentials Rx 41 (HMO) plan has a $299.00 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have a $12 copay at preferred pharmacies, while preferred brand drugs have a 31% coinsurance. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The PacificSource Medicare Essentials Rx 41 (HMO) plan offers a range of benefits with varying costs. For hospital stays, you'll pay a copay that varies depending on the type of service and the length of your stay. Outpatient services have copays, with some services having no copay. Emergency services, including ambulance, have copays, and primary care visits range from no copay to a $10 copay. Preventive services, such as checkups, often have no copay, and there are copays for hearing and vision services, including exams and eyewear. Dental services have a copay for Medicare-covered services, and medical equipment is covered with coinsurance. Prescription hearing aids are covered with a copay, and home health services have no copay.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you'll pay a $395 copay for days 1-7, and no copay for days 8-90; for Inpatient Hospital Psychiatric, you'll pay a $330 copay for days 1-5, and no copay for days 6-90. Additional Days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days for Inpatient Hospital Psychiatric and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay ranging from $0 to $360, and observation services with a $360 copay. Ambulatory Surgical Center (ASC) Services have no copay, and Outpatient Substance Abuse Services have a copay of $35 for both individual and group sessions. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under this plan with a $35 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the PacificSource Medicare Essentials Rx 41 (HMO) plan. Ground and air ambulance services have a $325 copay, but there is no coinsurance; transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage have a copay of $120, $55, $120, and $55, respectively, with no coinsurance. Worldwide Emergency Transportation has a copay of $325, with no coinsurance.
Primary Care See details
Primary Care Physician Services have a copay between $0 and $10, and Chiropractic Services have a $20 copay for routine care. Occupational Therapy Services, Physical Therapy, and Speech-Language Pathology Services have a $35 copay. Physician Specialist Services and Additional Telehealth Benefits have a copay between $0 and $35. Mental Health and Psychiatric Services for individual and group sessions have a $30 copay, and Opioid Treatment Program Services have a $35 copay.
Preventive Services See details
Preventive services include coverage for Medicare-covered preventive services with no copay, annual physical exams, and additional preventive services, with Alternative Therapies having a $25 copay per visit. Kidney Disease Education Services have a 20% coinsurance, and Other Preventive Services are covered, including Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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 Benefit, 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 (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing exams are covered with a $35 copay, and routine hearing exams are limited to 1 visit per year. Prescription hearing aids are covered, with a copay between $599 and $999, but inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Routine eye exams have a $35 copay, and are limited to one exam every two years. Other eye exam services, contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are covered with no copay or coinsurance. Eyewear has a combined maximum benefit of $200 every two years, and upgrades are not covered.
Dental Services See details
Dental Services are partially covered by the PacificSource Medicare Essentials Rx 41 (HMO) plan, with a $35 copay for Medicare Dental Services. However, Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
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 and 0-20% coinsurance. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the PacificSource Medicare Essentials Rx 41 (HMO) plan. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment is covered by the PacificSource Medicare Essentials Rx 41 (HMO) plan, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. Durable Medical Equipment has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a coinsurance between 0% and 20%, and Medical Supplies have a 20% coinsurance. Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have a coinsurance between 20% and 20%.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for diagnostic procedures/tests with a copay of $15 and coinsurance of at most 20%, lab services with no copay and coinsurance of at most 20%, diagnostic radiological services with a copay of at most $310, therapeutic radiological services with coinsurance of at most 20%, and outpatient X-ray services with no copay. Prior authorization is required.
Home Health Services See details
Home Health Services are covered with no copay and no coinsurance, but additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but the plan does not cover any of the sub-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, or Additional Cardiac Rehabilitation Services. There is a copay for these services, but since they are not covered, the copay is not applicable.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the PacificSource Medicare Essentials Rx 41 (HMO) plan, with no copay for days 1-20, and a $203 copay for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include acupuncture with a $25 copay, and over-the-counter items with an annual maximum of $100. Meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), 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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