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Pacific Source - Medicare Suppliment Plans
Plans With Prescription Drug Coverage |
Plans Without Prescription Drug Coverage |
2012 Plans with Medical and Prescription Drug Coverage All in One
Below is what you pay for covered services. This is a brief summary. Please contact us for details.
|
Essentials Rx 16 (HMO) $10 per month |
Explorer Rx 2 (PPO) $33 per month |
||
|---|---|---|---|
Doctor and Hospital Benefits |
In-Network | In-Network | Out-of-Network |
| Primary Care Visit | $10 copay | $10 copay | $20 copay |
| Specialist | $30 copay | $20 copay | $30 copay |
| Lab | $10 copay | $10 copay | 20% coinsurance |
| X-Ray | $10 copay | $10 copay | 20% coinsurance |
| Hospitalization | $175/day (days 1-7) $0/day (days 8+) |
$125/day (days 1-5) $0/day (days 6+) |
$175/day (days 1-6) $0/day (days 7+) |
| Outpatient Surgery | $175 copay | $150 copay | $150 copay |
| Out-of-Pocket Limit | $2,500 | 2,500 in/out combined | |
Part D Prescription Drug Benefits |
|||
| Stage 1: | What you pay until total drug costs1 reach $2,930 | ||
| Deductible | $0 | $0 | |
| Generic (31/93 day) | $5/$10 copay | $5/$10 copay | |
| Preferred Brand (31/93 day) | $40/$100 copay | $40/$100 copay | |
| Non-Preferred Brand (31/93 day) | $80/$240 copay | $80/$240 copay | |
| Specialty | 33% coinsurance | 33% coinsurance | |
| Stage Two: | What you pay after your total drug costs1 reach $2,930 | ||
| Generic | 86% coinsurance | 86% coinsurance | |
| Brand Name Drugs | 50% discount | 50% discount | |
| Stage Three: | After your out-of-pocket2 costs reach $4,700, the maximum you pay until the end of the calendar year | ||
| All Covered Drugs | 5% coinsurance | 5% coinsurance | |
1 Total drug costs include: Both what you pay and what PacificSource Medicare pays for your prescriptions.
2 Out-of-pocket costs include: Everything you've paid during Stage One and Stage Two.
2012 Plans without Prescription Drug Coverage
Below is what you pay for covered services. This is a brief summary. Please contact us for details.
|
Explorer 6 (PPO) $0 per month |
||
|---|---|---|
Doctor and Hospital Benefits |
In-Network | Out-of-Network |
| Primary Care Visit | $10 copay | $20 copay |
| Specialist | $20 copay | $30 copay |
| Lab | $10 copay | 20% coinsurance |
| X-Ray | $10 copay | 20% coinsurance |
| Hospitalization | $125/day (days 1-5) $0/day (days 6+) |
$175/day (days 1-6) $0/day (days 7+) |
| Outpatient Surgery | $150 copay | $150 copay |
| Out-of-Pocket Limit | $2,500 in/out combined | |