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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 2026, 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 out of 5 stars in 2026.
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 $157.00. 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 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 features an annual drug deductible of $499. For Tier 1 preferred generic drugs, members pay no copay at standard pharmacies or through standard mail order for up to a three-month supply. Tier 2 generic drugs require a $6 copay for a one-month supply at standard pharmacies, while standard mail order offers a flat $6 copay for one, two, or three-month supplies. For brand-name and specialty medications, cost-sharing is based on coinsurance. Tier 3 preferred brand drugs carry a 20% coinsurance at standard pharmacies and a lower 15% coinsurance through standard mail order. Tier 4 non-preferred drugs require 25% coinsurance for both pharmacy and mail order fills, while Tier 5 specialty drugs incur a 27% coinsurance for a one-month supply.
Additional Benefits
The PacificSource Medicare Explorer Rx 4 (PPO) plan offers robust medical coverage with affordable out-of-pocket costs, featuring doctor visits that range from no copay to a $40 copay. Inpatient hospital stays require no coinsurance and a $450 daily copay for the first six days, while emergency room visits carry a $120 copay. Outpatient services, diagnostic tests, and urgent care are also covered with minimal copays and low coinsurance. Supplemental benefits include preventive dental care with no copay up to a $500 annual limit, and routine eye exams for a $35 copay. Routine hearing exams cost a $30 copay, and prescription hearing aids are covered with copays between $599 and $999. Furthermore, members enjoy no copays on home health services, annual wellness visits, and up to $100 annually for over-the-counter items.
Inpatient Hospital See details
Inpatient hospital services are covered by PacificSource Medicare Explorer Rx 4 (PPO) with no coinsurance, though prior authorization is required. For acute care, there is a $450 daily copay for days 1 to 6 and no copay for days 7 and beyond, while psychiatric care requires a $330 daily copay for days 1 to 5 and no copay for days 6 to 90. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by PacificSource Medicare Explorer Rx 4 (PPO) with no coinsurance, including ambulatory surgical center and blood services for no copay. Outpatient hospital visits require a copay of $0 to $450, observation services cost a $450 copay per stay, and outpatient substance abuse sessions have a $35 copay.
Partial Hospitalization See details
Partial hospitalization is covered under the PacificSource Medicare Explorer Rx 4 (PPO) plan with a $35.00 copay and no coinsurance. Prior authorization is required to access these services.
Ambulance and Transportation Services See details
PacificSource Medicare Explorer Rx 4 (PPO) partially covers ambulance and transportation services, with ground and air ambulance services requiring a $275 copay and no coinsurance. While some transportation services are covered, transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
PacificSource Medicare Explorer Rx 4 (PPO) covers emergency services with a $120 copay and no coinsurance, which is waived if you are admitted to the hospital within 72 hours. Urgently needed services are covered with a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $120, $50, and $275 respectively.
Primary Care See details
PacificSource Medicare Explorer Rx 4 (PPO) offers partially covered primary care services with no coinsurance and copays ranging from no copay up to $40. While most services like primary care visits, specialist consultations, and physical therapy are covered, podiatry and other chiropractic services are not covered.
Preventive Services See details
PacificSource Medicare Explorer Rx 4 (PPO) covers most 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, featuring alternative therapies for a $25 copay and no coinsurance alongside fitness benefits, while excluding services such as health education, weight management, and nutritional counseling.
Hearing Services See details
Hearing services are partially covered by PacificSource Medicare Explorer Rx 4 (PPO), which features a $30 copay and no coinsurance for routine hearing exams, and copays ranging from $599 to $999 with no coinsurance for up to two prescription hearing aids annually. OTC hearing aids, as well as inner ear, outer ear, and over-the-ear prescription hearing aids, are not covered.
Vision Services See details
Vision services are partially covered by PacificSource Medicare Explorer Rx 4 (PPO), with eyewear upgrades not covered. Routine eye exams have a $35 copay and no coinsurance (limited to one every two years), while covered eyewear has no copay or coinsurance up to a $200 combined maximum limit every two years, with no deductibles.
Dental Services See details
Dental services are partially covered by PacificSource Medicare Explorer Rx 4 (PPO), featuring a $35 copay and no coinsurance for Medicare-covered dental, and preventive care with no copay or coinsurance up to a $500 annual limit. Comprehensive services require no copay and 50% coinsurance, though maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
PacificSource Medicare Explorer Rx 4 (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Associated Medicare Part B chemotherapy, radiation, and other drugs require no coinsurance to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by the PacificSource Medicare Explorer Rx 4 (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered under the PacificSource Medicare Explorer Rx 4 (PPO) with no copay and a 20% coinsurance for durable medical equipment, medical supplies, and diabetic equipment. Prosthetic devices are also covered with no copay and a coinsurance ranging from no coinsurance to 20%, with prior authorization required for these services.
Diagnostic and Radiological Services See details
PacificSource Medicare Explorer Rx 4 (PPO) covers diagnostic and radiological services with prior authorization. Diagnostic tests require a $15 copay and 20% coinsurance, lab services have no copay and 20% coinsurance, X-rays have no copay but require coinsurance, and diagnostic radiological services have no copay or coinsurance.
Home Health Services See details
PacificSource Medicare Explorer Rx 4 (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
PacificSource Medicare Explorer Rx 4 (PPO) covers some Cardiac Rehabilitation Services with no copay and no coinsurance, although standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
PacificSource Medicare Explorer Rx 4 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 to 20 and a $203 daily copay for days 21 to 100. Prior authorization is required, and a prior three-day inpatient hospital stay is not required for admission.
Other Services See details
PacificSource Medicare Explorer Rx 4 (PPO) partially covers other services, offering acupuncture for a $25 copay and no coinsurance up to 12 treatments per year, and annual wellness visits with no copay and no coinsurance. Over-the-counter items are also covered with no copay and no coinsurance up to $100 annually, while meal benefits, nicotine replacement therapy, and naloxone are not covered.
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