Plans for PacificSource Medicare

41,124 Total Members

Prescription Hearing Aid Coverage
Company Plan name Plan type OTC Supplement OTC Rolls Over? Annual OTC Supplement Coverage? Covered Amount Coinsurance? Copay? Prior Authorization? Need Referral? Enrollees
PacificSource Medicare PacificSource Medicare Essentials Choice Rx 36 (HMO-POS)
H3864-036-0 		HMOPOS $25 per Quarter No $100 Yes No Yes No No 5,925
PacificSource Medicare PacificSource Dual Care (HMO D-SNP)
H3864-043-0 		HMO $200 per Quarter No $800 No 5,201
PacificSource Medicare PacificSource Medicare Essentials Choice Rx 14 (HMO-POS)
H3864-014-0 		HMOPOS $25 per Quarter No $100 Yes No Yes No No 4,310
PacificSource Medicare PacificSource Medicare Explorer Rx 11 (PPO)
H4754-011-0 		Local PPO $25 per Quarter No $100 Yes No Yes No No 4,282
PacificSource Medicare PacificSource Medicare MyCare Choice Rx 24 (HMO-POS)
H3864-024-0 		HMOPOS $25 per Quarter No $100 Yes No Yes No No 4,092
PacificSource Medicare PacificSource Medicare MyCare Rx 40 (HMO)
H3864-040-0 		HMO $25 per Quarter No $100 Yes No Yes No No 2,803
PacificSource Medicare PacificSource Medicare Essentials Rx 27 (HMO)
H3864-027-0 		HMO $45 per Quarter No $180 Yes No Yes No No 2,426
PacificSource Medicare PacificSource Medicare Essentials Choice 2 (HMO-POS)
H3864-002-0 		HMOPOS $150 per Quarter No $600 Yes No Yes No No 2,225
PacificSource Medicare PacificSource Medicare Essentials Rx 41 (HMO)
H3864-041-0 		HMO $100 per Month No $0 Yes No Yes No No 1,350
PacificSource Medicare PacificSource Medicare MyCare Rx 32 (HMO)
H3864-032-0 		HMO $25 per Quarter No $100 Yes No Yes No No 1,312
PacificSource Medicare PacificSource Medicare Essentials Rx 803 (HMO)
H3864-803-0 		HMO No $0 No 1,184
PacificSource Medicare PacificSource Medicare Explorer Rx 9 (PPO)
H4754-009-0 		Local PPO $100 per Month No $0 Yes No Yes No No 1,140
PacificSource Medicare PacificSource Medicare Essentials Rx 6 (HMO)
H3864-006-0 		HMO $25 per Quarter No $100 Yes No Yes No No 790
PacificSource Medicare PacificSource Medicare MyCare Choice Rx 29 (HMO-POS)
H3864-029-0 		HMOPOS $50 per Quarter No $200 Yes No Yes No No 746
PacificSource Medicare PacificSource Medicare Explorer 6 (PPO)
H4754-006-0 		Local PPO $150 per Quarter No $600 Yes No Yes No No 722
PacificSource Medicare PacificSource Medicare Explorer 12 (PPO)
H4754-012-0 		Local PPO $150 per Quarter No $600 Yes No Yes No No 689
PacificSource Medicare PacificSource Medicare MyCare Choice Rx 34 (HMO-POS)
H3864-034-0 		HMOPOS $25 per Quarter No $100 Yes No Yes No No 622
PacificSource Medicare PacificSource Medicare Explorer Rx 4 (PPO)
H4754-004-0 		Local PPO $100 per Month No $0 Yes No Yes No No 535
PacificSource Medicare PacificSource Medicare Explorer Rx 7 (PPO)
H4754-007-0 		Local PPO $100 per Month No $0 Yes No Yes No No 244
PacificSource Medicare PacificSource Medicare Essentials Choice Rx 42 (HMO-POS)
H3864-042-0 		HMOPOS $25 per Quarter No $100 Yes No Yes No No 195
PacificSource Medicare PacificSource Medicare Explorer 8 (PPO)
H4754-008-0 		Local PPO $100 per Quarter No $400 Yes No Yes No No 172
PacificSource Medicare PacificSource Medicare Explorer Rx 17 (PPO)
H4754-017-0 		Local PPO $100 per Month No $0 Yes No Yes No No 83
PacificSource Medicare PacificSource Medicare MyCare Choice 30 (HMO-POS)
H3864-030-0 		HMOPOS $200 per Quarter No $800 Yes No Yes No No 76
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