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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 2026, 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 2026.
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 $127.00. 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 $499.00 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 $6700.00 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 features an annual drug deductible of $499. Under this plan, Tier 1 preferred generic drugs have no copay for up to a three-month supply through standard pharmacies and standard mail order. Tier 2 generic drugs require a $6 copay for a one-month supply at standard pharmacies, while standard mail-order options offer a flat $6 copay for one, two, or three-month supplies. Higher-tier medications are covered under coinsurance, with Tier 3 preferred brand drugs costing 20% coinsurance at standard pharmacies and a reduced 15% coinsurance through standard mail order. Tier 4 non-preferred drugs carry a 25% coinsurance for both standard pharmacy and standard mail-order fills. Specialty drugs in Tier 5 require a 27% coinsurance for a one-month supply at standard pharmacies or through standard mail order.
Additional Benefits
The PacificSource Medicare Essentials Rx 41 (HMO) plan offers robust coverage for essential medical services with predictable copays and no coinsurance for many key benefits. Inpatient hospital stays require a $450 daily copay for the first six days and no copay thereafter, while primary care visits range from no copay up to $35. Additionally, emergency care has a $120 copay, and skilled nursing facility stays feature no copay for the first 20 days. Preventive services and home health care are fully covered with no copays or coinsurance, and members receive a $200 biennial eyewear allowance and a $100 annual over-the-counter benefit. Routine hearing exams require a $25 copay, while diagnostic tests, dialysis, and durable medical equipment generally require a 20% coinsurance. Medicare-covered dental services are available with a $35 copay, though routine dental care is not covered under this plan.
Inpatient Hospital See details
PacificSource Medicare Essentials Rx 41 (HMO) covers inpatient acute hospital stays with no coinsurance, requiring a $450 daily copay for days 1 to 6 and no copay for days 7 and beyond. Inpatient psychiatric care is also covered with no coinsurance, featuring a $330 daily copay for days 1 to 5 and no copay for days 6 to 90. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, and prior authorization is required.
Outpatient Services See details
PacificSource Medicare Essentials Rx 41 (HMO) covers outpatient services with no coinsurance, featuring a $0 to $450 copay for outpatient hospital services and a $450 copay per stay for observation services. Ambulatory surgical center and outpatient blood services have no copay and no coinsurance, while outpatient substance abuse sessions require a $35 copay and no coinsurance.
Partial Hospitalization See details
PacificSource Medicare Essentials Rx 41 (HMO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required for this covered benefit.
Ambulance and Transportation Services See details
PacificSource Medicare Essentials Rx 41 (HMO) covers ground and air ambulance services with a $325 copay and no coinsurance, though prior authorization is required. Routine transportation services to plan-approved or other health-related locations are not covered under this plan.
Emergency Services See details
PacificSource Medicare Essentials Rx 41 (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 Essentials Rx 41 (HMO) primary care benefits are partially covered, featuring copays ranging from no copay up to $35 and no coinsurance for all covered services. Podiatry services and other chiropractic services are not covered under this plan.
Preventive Services See details
Preventive Services are partially covered by PacificSource Medicare Essentials Rx 41 (HMO), featuring annual physical exams and routine screenings with no copay and no coinsurance. While alternative therapies (up to 12 visits with a $25 copay and no coinsurance) and kidney disease education (no copay with 20% coinsurance) are covered, various supplemental benefits such as health education, nutritional benefits, and in-home support are not covered.
Hearing Services See details
PacificSource Medicare Essentials Rx 41 (HMO) partially covers hearing services, offering routine hearing exams for a $25 copay and no coinsurance, alongside prescription hearing aids with copays ranging from $599 to $999 and no coinsurance. However, OTC hearing aids and inner ear, outer ear, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision services are partially covered by PacificSource Medicare Essentials Rx 41 (HMO) with no deductibles, featuring routine eye exams for a $35 copay and other eye exams with no coinsurance. Eyewear is covered with no copay or coinsurance up to a $200 limit every two years, though upgrades are not covered.
Dental Services See details
PacificSource Medicare Essentials Rx 41 (HMO) dental services are partially covered, limiting coverage to Medicare-covered dental services with a $35.00 copay, no coinsurance, and prior authorization required. Routine preventive and comprehensive sub-services, including oral exams, cleanings, x-rays, fluoride, restorative care, endodontics, periodontics, implants, and orthodontics, are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by PacificSource Medicare Essentials Rx 41 (HMO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs have 0% to 20% coinsurance, while Part B insulin drugs require a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by PacificSource Medicare Essentials Rx 41 (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by PacificSource Medicare Essentials Rx 41 (HMO) with no copay and prior authorization required. Durable medical equipment, medical supplies, and diabetic equipment require a 20% coinsurance, while prosthetic devices range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under PacificSource Medicare Essentials Rx 41 (HMO) with prior authorization required. Diagnostic tests require a $15 copay and 20% coinsurance, lab services require no copay and 20% coinsurance, and diagnostic radiological services have no copay and no coinsurance. Therapeutic radiological services require a copay and 20% coinsurance, while outpatient X-rays require no copay but do require coinsurance.
Home Health Services See details
Home health services are covered by PacificSource Medicare Essentials Rx 41 (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
PacificSource Medicare Essentials Rx 41 (HMO) covers Cardiac Rehabilitation Services with no coinsurance, though copays apply to individual services. You will pay a $35 copay for cardiac and intensive cardiac rehabilitation, a $15 copay for pulmonary rehabilitation, and a $25 copay for supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD).
Skilled Nursing Facility (SNF) See details
PacificSource Medicare Essentials Rx 41 (HMO) covers skilled nursing facility (SNF) care with no coinsurance, offering no copay for days 1 through 20 and a $203 copayment per day for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required for admission, and additional days beyond the standard 100-day limit are not covered.
Other Services See details
Other services are partially covered by PacificSource Medicare Essentials Rx 41 (HMO), including acupuncture for a $25 copay and no coinsurance up to 12 treatments per year, and an annual wellness visit with no copay or coinsurance. Over-the-counter (OTC) items are also covered with no copay or coinsurance up to $100 annually, though meal benefits, nicotine replacement therapy, and naloxone are not covered.
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