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PacificSource Medicare MyCare Rx 40 (HMO)

H3864 - 040 - 0

(3.5 / 5)

PacificSource Medicare MyCare Rx 40 (HMO) is a Medicare Advantage Plan by PacificSource Medicare.

This page features plan details for 2025 PacificSource Medicare MyCare Rx 40 (HMO) H3864 – 040 – 0 available in Select Oregon and Washington Counties.

Locations

PacificSource Medicare MyCare Rx 40 (HMO) is offered in the following locations.

Clackamas County, Oregon

Clark County, Washington

Multnomah County, Oregon

Click to see more locations

Plan Overview

PacificSource Medicare MyCare Rx 40 (HMO) offers the following coverage and cost-sharing.

Insurer:	PacificSource Medicare
Health Plan Deductible:	$500 In-network
MOOP:	$5,800 In-network
Drugs Covered:	Yes

Ready to sign up for PacificSource Medicare MyCare Rx 40 (HMO) ?

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 MyCare Rx 40 (HMO) has a monthly premium of $0.00. 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	$0.00	$	$

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 MyCare Rx 40 (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$150.00
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 D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $150.00 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.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$8.00 Copay		$8.00 Copay
2) Generic	$9.00 Copay	$17.00 Copay	$9.00 Copay	$17.00 Copay
3) Preferred Brand	$47.00 Copay	$47.00 Copay	$47.00 Copay	$47.00 Copay
4) Non-Preferred Drug	31.00% Coinsurance	33.00% Coinsurance	31.00% Coinsurance	33.00% Coinsurance
5) Specialty Tier	31.00% Coinsurance	31.00% Coinsurance	31.00% Coinsurance	31.00% Coinsurance

60 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$16.00 Copay		$16.00 Copay
2) Generic	$18.00 Copay	$34.00 Copay	$18.00 Copay	$34.00 Copay
3) Preferred Brand	$94.00 Copay	$94.00 Copay	$94.00 Copay	$94.00 Copay
4) Non-Preferred Drug	31.00% Coinsurance	33.00% Coinsurance	31.00% Coinsurance	33.00% Coinsurance
5) Specialty Tier

90 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$24.00 Copay		$24.00 Copay
2) Generic	$27.00 Copay	$51.00 Copay	$18.00 Copay	$51.00 Copay
3) Preferred Brand	$141.00 Copay	$141.00 Copay	$94.00 Copay	$141.00 Copay
4) Non-Preferred Drug	31.00% Coinsurance	33.00% Coinsurance	31.00% Coinsurance	33.00% Coinsurance
5) Specialty Tier

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 MyCare Rx 40 (HMO) 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)
Fluoride Treatment
- In-Network: No Coins – No Copay (Limits Apply)
Oral Exams
- In-Network: No Coins – No Copay (Limits Apply)
Other Diagnostic Dental Services
- In-Network: No Coins – No Copay (Limits Apply)
Other Preventive Dental Services
- In-Network: No Coins – No Copay (Limits Apply)
Prophylaxis (cleaning)
- In-Network: No Coins – No Copay (Limits Apply)

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures
- 20% coinsurance (Authorization Required)
Diagnostic radiology services (e.g., MRI)
- $0-320 copay (Authorization Required)
Lab services
- 0-20% coinsurance (Authorization Required)
Outpatient x-rays
- $0 copay (Authorization Required)

Doctor visits

Specialist
- $0-30 copay per visit (Authorization Required)
Primary
- $0 copay

Emergency care/Urgent care

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

Foot care (podiatry services)

Routine foot care
- Not covered
Foot exams and treatment
- $30 copay

Ground ambulance

- $325 copay

Health plan deductible

- $500 In-network

Hearing

Hearing aids OTC
- Not covered
Hearing aids
- $599-999 copay (Limits Apply)
Fitting/evaluation
- $0 copay
Medicare-Covered Hearing Exam
- $35 copay

Inpatient hospital coverage

- $395 per day for days 1 through 7
  $0 per day for days 8 through 90

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

- $5,800 In-network

Medical equipment/supplies

Durable medical equipment (e.g., wheelchairs, oxygen)
- 20% coinsurance per item (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- 0-20% coinsurance per item (Authorization Required)
Diabetes supplies
- 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

Other Part B drugs
- 0-20% coinsurance (Authorization Required)
Chemotherapy
- 0-20% coinsurance (Authorization Required)

Mental health services

Inpatient hospital – psychiatric
- $330 per day for days 1 through 5
  $0 per day for days 6 through 90
Outpatient group therapy visit
- $35 copay
Outpatient individual therapy visit
- $35 copay
Outpatient group therapy visit with a psychiatrist
- $35 copay
Outpatient individual therapy visit with a psychiatrist
- $35 copay

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $0-395 copay per visit (Authorization Required)

Preventive care

- $0 copay

Rehabilitation services

Occupational therapy visit
- $5 copay
Physical therapy and speech and language therapy visit
- $5 copay

Skilled Nursing Facility

- $0 per day for days 1 through 20
  $203 per day for days 21 through 100

Transportation

- Not covered

Vision

Upgrades
- Not covered
Eyeglass frames
- $0 copay (Limits Apply)
Eyeglass lenses
- $0 copay (Limits Apply)
Other
- $0 copay
Routine eye exam
- $0 copay (Limits Apply)
Contact lenses
- $0 copay (Limits Apply)
Eyeglasses (frames and lenses)
- $0 copay (Limits Apply)

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

- Covered