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PacificSource Medicare Explorer Rx 18 (PPO)

H4754 - 018 - 0
3.5 out of 5 stars (3.5 / 5)

PacificSource Medicare Explorer Rx 18 (PPO) is a Medicare Advantage Plan by PacificSource Medicare.

This page features plan details for 2025 PacificSource Medicare Explorer Rx 18 (PPO) H4754 – 018 – 0 available in Select Idaho and Montana Counties.

Locations

PacificSource Medicare Explorer Rx 18 (PPO) is offered in the following locations.

Ada County, Idaho
Blaine County, Idaho
Boise County, Idaho

Click to see more locations

Plan Overview

PacificSource Medicare Explorer Rx 18 (PPO) offers the following coverage and cost-sharing.

Insurer:PacificSource Medicare
Health Plan Deductible:$0
MOOP:$8,950 In and Out-of-network
$6,700 In-network
Drugs Covered:Yes

Ready to sign up for PacificSource Medicare Explorer Rx 18 (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

PacificSource Medicare Explorer Rx 18 (PPO) has a monthly premium of $29.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $29.00 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

PacificSource Medicare Explorer Rx 18 (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $499.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$29.00$0.00

Initial Coverage Phase

After you pay your $499.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

PacificSource Medicare Explorer Rx 18 (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Endodontics
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Implant Services
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Periodontics
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: 50 Coins – No Co pay (Limits Apply)
  • Restorative Services
    • In-Network: 50 Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Fluoride Treatment
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Oral Exams
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Other Diagnostic Dental Services
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Other Preventive Dental Services
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)

Diagnostic procedures/lab services/imaging

  • Diagnostic tests and procedures
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Lab services
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $15 copay or 20% coinsurance (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $0-430 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $0-15 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: 50% coinsurance (Authorization Required)

Doctor visits

  • Primary
    • In-Network: $0-10 copay per visit
    • Out-of-Network: 50% coinsurance per visit
  • Specialist
    • In-Network: $40 copay per visit (Authorization Required)
    • Out-of-Network: 50% coinsurance per visit (Authorization Required)

Emergency care/Urgent care

  • Emergency
    • $120 copay per visit (always covered)
  • Urgent care
    • $55 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • Out-of-Network: 50% coinsurance
    • In-Network: $40 copay
  • Routine foot care
    • Not covered

Ground ambulance

    • Out-of-Network: $350 copay
    • In-Network: $350 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • In-Network: $0 copay
  • Hearing aids
    • In-Network: $599-999 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • Out-of-Network: 50% coinsurance
  • Fitting/evaluation
    • Out-of-Network: $0 copay
  • Hearing aids
    • Out-of-Network: $599-999 copay (Limits Apply)
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • In-Network: $40 copay

Inpatient hospital coverage

    • In-Network: $425 per day for days 1 through 7
      $0 per day for days 8 through 90
    • Out-of-Network: 50% per stay

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $8,950 In and Out-of-network
      $6,700 In-network

Medical equipment/supplies

  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: 50% coinsurance per item (Authorization Required)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 50% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 50% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: $35 copay or 50% coinsurance (Authorization Required)
  • Chemotherapy
    • Out-of-Network: $35 copay or 50% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • In-Network: $325 per day for days 1 through 7
      $0 per day for days 8 through 90
    • Out-of-Network: 50% per stay
  • Outpatient group therapy visit
    • In-Network: $40 copay
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $40 copay
  • Outpatient group therapy visit
    • Out-of-Network: 50% coinsurance
  • Outpatient individual therapy visit
    • Out-of-Network: 50% coinsurance
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $40 copay
    • Out-of-Network: 50% coinsurance
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 50% coinsurance
  • Outpatient individual therapy visit
    • In-Network: $40 copay

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: 50% coinsurance per visit (Authorization Required)
    • In-Network: $0-425 copay per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: 50% coinsurance

Rehabilitation services

  • Physical therapy and speech and language therapy visit
    • Out-of-Network: 50% coinsurance
    • In-Network: $40 copay
  • Occupational therapy visit
    • In-Network: $40 copay
    • Out-of-Network: 50% coinsurance

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $203 per day for days 21 through 100
    • Out-of-Network: 50% per stay

Transportation

    • Not covered

Vision

  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Other
    • In-Network: $0 copay
    • Out-of-Network: 50% coinsurance
  • Upgrades
    • Not covered

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for PacificSource Medicare Explorer Rx 18 (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

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