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Medicare Advantage · HMO
PacificSource Medicare
Plan year 2026

PacificSource Medicare MyCare Rx 40 H3864-040 (HMO)

3.5 · 2026 Star Rating · source: CMS · Ratings are updated annually
Monthly premium
$0
+ your Part B premium
Max out-of-pocket
$6,750
in-network annual cap
Primary care
$20
per visit copay
Specialist
$30
per visit

Your costs at a glanceIn-network, for the 2026 plan year

Medical deductible
$500
Rx deductible
$399
Inpatient hospital
Days 1-7: $435/day, Days 8-90: $0/day
no limit on covered hospital days
Inpatient mental health
Days 1-7: $325/day, Days 8-90: $0/day
Outpatient surgery
$425
Emergency room
$120
Urgent care
$50

What's included, and what it's actually worth5 benefits included. Tap any card for the detail

Dental

$750/yr allowance
Annual max$750/yr allowance
This is a supplemental benefit with plan-specific limits. See plan documents for details.

Hearing

$599–$999copay per hearing aid
Details$599–$999 copay per hearing aid
This is a supplemental benefit with plan-specific limits. See plan documents for details.

Vision

$200eyewear allowance per 2 years
Eyewear allowance$200 eyewear allowance per 2 years
This is a supplemental benefit with plan-specific limits. See plan documents for details.

OTC allowance

$25/quarter OTC allowance
Prepaid card$25/quarter OTC allowance
See more details about this plan
Doctor Visits: PCP$20 copay
In-network$20 copay per visit
Doctor Visits: Specialist$30 copay
In-network$30 copay per visit
Inpatient Hospital$435/day, days 1–7
In-networkDays 1-7: $435/day, Days 8-90: $0/day
Benefit limitNone — additional covered days are unlimited
Outpatient Surgery$425 copay
In-network$425 copay per procedure
Mental HealthDays 1-7: $325/day, Days 8-90: $0/day
Inpatient psychiatricDays 1-7: $325/day, Days 8-90: $0/day
MealsMeal benefit

Your coverageCheck your coverageFrom the doctors and prescriptions you added

Your plan's drug tiers30-day retail · after any applicable deductible

Tier 1
$0
Preferred Generic
Tier 2
$6
Generic
Tier 3
24%
Preferred Brand· after deductible
Tier 4
28%
Non-Pref Brand· after deductible
Tier 5
28%
Specialty· after deductible

Our take

Where this plan shines

This plan has a $0 monthly premium.

Things to know before you enroll

This plan’s out-of-pocket maximum is above the national median.
Network restriction — you’ll need to use in-network providers except in emergencies.
Limited coverage while traveling outside the plan’s service area.
Questions? Talk to a licensed agent at1-866-764-3312 (TTY: 711)

Plan documents

Summary of Benefits (PDF)
Download the plan's official Summary of Benefits document
Evidence of Coverage (PDF)
Complete plan details and rules
Check Your Doctors
See if your doctors accept this plan
Documentos en español
Llame al (888)863-3637 (TTY: 711) para solicitar documentos en español

Helpful next steps

The Pocket Protector · NPN 21126942 · 1-866-764-3312 (TTY: 711) · thepocketprotector.com

Plan benefits, premiums, and copays may vary by county and plan. You must continue to pay your Medicare Part B premium. Benefits and costs may vary by service area. Contact the plan or CMS for complete details.

We do not offer every plan available in your area. Currently we represent a limited number of organizations which offer a limited number of products in your area. Please contact Medicare.gov, 1-800-MEDICARE (TTY: 1-877-486-2048), or your local State Health Insurance Program (SHIP) to get information on all of your options.

Every year, Medicare evaluates plans based on a 5-star rating system. Star ratings are based on 2026 data and may change annually.

Members may receive a monthly or quarterly allowance in the form of a benefits prepaid card to pay for a wide range of plan-approved items. Unused amounts will expire at the end of the month or quarter.

Out-of-network/non-contracted providers are under no obligation to treat plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you to contact the plan.

Dental, hearing, vision, and other supplemental benefits may have limitations and restrictions. These benefits vary by plan. Please refer to the plan's Evidence of Coverage for details.

The plan formulary, pharmacy network, and/or copays may change at any time. You will receive notice when necessary.

Benefits shown are based on CMS public plan data. Actual benefits vary by county. Not all plans available in all areas. Speak with a licensed agent before enrolling.

  1. The Pocket Protector represents Medicare Advantage HMO, PPO, and PFFS organizations and stand-alone PDP prescription drug plans that have a Medicare contract. Enrollment depends on the plan's contract renewal.
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