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PacificSource Medicare Explorer Rx 4 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for PacificSource Medicare Explorer Rx 4 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on PacificSource Medicare Explorer Rx 4 (PPO) in 2025, please refer to our full plan details page.
PacificSource Medicare Explorer Rx 4 (PPO) is a PPO 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 Explorer Rx 4 (PPO) 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 Explorer Rx 4 (PPO).
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 Explorer Rx 4 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $123.00. 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 $250.00 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 Explorer Rx 4 (PPO) plan has a $250 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'll pay a $12 copay at preferred pharmacies and $17 at standard pharmacies, and for standard generic drugs, the copay is $47 regardless of pharmacy. Preferred brand drugs have a 31% coinsurance at preferred pharmacies and 32% at standard pharmacies.
Additional Benefits
The PacificSource Medicare Explorer Rx 4 (PPO) plan offers a variety of benefits with varying costs. Inpatient hospital stays have copays, while outpatient services have copays ranging from $0 to $425. Emergency services have copays, and primary care visits have a $0-$10 copay. This plan also covers preventive services, hearing, vision, and dental services. Hearing exams and routine eye exams each have a $35 copay, while dental services have a $35 copay for Medicare dental services, and other services are covered up to a $500 maximum per year. Additional benefits include ambulance, home health, and skilled nursing facility services.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $425 copay for days 1-7, and no copay for days 8-90. For Inpatient Hospital Psychiatric, you will pay a $330 copay for days 1-5, and no copay for days 6-90. The plan does not cover Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, or Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $425, observation services with a $425 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services are covered, with individual and group sessions each having a copay of $35. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial hospitalization is covered by the PacificSource Medicare Explorer Rx 4 (PPO) plan. You will pay a $35 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the PacificSource Medicare Explorer Rx 4 (PPO) plan. Medicare-covered Ground and Air Ambulance Services have a $275 copay, and there is no coinsurance. 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. Emergency Services have a $120 copay, and Urgently Needed Services have a $55 copay, while Worldwide Emergency Coverage has a $120 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $275 copay.
Primary Care See details
The PacificSource Medicare Explorer Rx 4 (PPO) plan covers primary care physician services with a copay of $0 - $10. Chiropractic services have a $20 copay, while routine chiropractic care has a $25 copay for up to 12 visits per year. Occupational Therapy Services have a $35 copay, and Physician Specialist Services have a copay of $0 - $40. Mental Health Specialty Services, Individual Sessions for Mental Health Specialty Services, and Group Sessions for Mental Health Specialty Services have a $30 copay, while Other Health Care Professional services have a copay of $10 - $40. Individual and Group Sessions for Psychiatric Services also have a $30 copay. Physical Therapy and Speech-Language Pathology Services have a $35 copay, and Additional Telehealth Benefits have a copay of $0 - $40. Finally, Opioid Treatment Program Services have a $35 copay.
Preventive Services See details
The PacificSource Medicare Explorer Rx 4 (PPO) plan covers preventive services, including annual physical exams and additional preventive services. Additional preventive services may have a copay, and alternative therapies have a $25 copay per visit for up to 12 visits. Kidney Disease Education Services have a 20% coinsurance. The plan does not cover Health Education, In-Home Safety Assessment, Personal Emergency Response System, 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 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, Home and Bathroom Safety Devices and Modifications, and Counseling Services.
Hearing Services See details
Hearing Services include routine hearing exams with a $35 copay, and fitting/evaluation for hearing aids. 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, nor are OTC hearing aids.
Vision Services See details
Vision services include eye exams and eyewear. Routine eye exams have a $35 copay, and you are limited to one exam every two years. Eyewear has a combined maximum benefit of $200 every two years for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Upgrades are not covered.
Dental Services See details
Dental Services include a $35 copay for Medicare Dental Services, and other services are covered up to a $500 maximum per year. Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Implant Services, and Oral and Maxillofacial Surgery have a 50% coinsurance, while Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B insulin drugs, there is a $35 copay and coinsurance between 0% and 20%. Medicare Part B chemotherapy/radiation drugs and other Medicare Part B drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the PacificSource Medicare Explorer Rx 4 (PPO) plan. The coinsurance for dialysis services is between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance for Medicare-covered services, and Diabetic Equipment. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures/tests with a copay of at least $15 and at most $15 and a coinsurance of at most 20%, and lab services with no copay and a coinsurance of at most 20%. Additionally, diagnostic radiological services have a copay of at most $310, while therapeutic radiological services have a coinsurance of at most 20%, and outpatient x-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the PacificSource Medicare Explorer Rx 4 (PPO) 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 by the PacificSource Medicare Explorer Rx 4 (PPO) plan, though the specific copay is not listed. However, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the PacificSource Medicare Explorer Rx 4 (PPO) plan, with no copay for days 1-20 and a $203 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services include acupuncture with a $25 copay for up to 12 treatments per year, and over-the-counter items with a maximum benefit of $100 per year. Meal Benefit, 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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