In-network
Inpatient hospital
Days 1–6 $450 / day
Days 7–90 $0 / day
Total of listed copays · 6 charged days $2,700
● CMS 2026 plan record
PacificSource Medicare Explorer Rx 4 (PPO)
Emergency transport
Ambulance
Ground · in-network$275 copay
Air · in-network$275 copay
Emergency services
Emergency room
$120 copay
Waived if admitted within 72 hours
Medical maximum
Maximum out-of-pocket
In-network$6,700
Combined in + out$8,950
Skilled care at home
Home health
In-networkNo cost share reported
Out-of-network50% coinsurance
Monthly cost
Premium & giveback
Part C premium$68.30 / month
Consolidated C + D$157 / month
Source trail
Official CMS, Contract Year 2026
Plan identity and benefits come from CMS PBP data. Premium and MOOP figures are cross-checked against the August 2026 Landscape release. Quick-reference values should be confirmed in current official plan documents.
About this code
What H4754-004-000 identifies
H4754-004-000 is a Contract Year 2026 Medicare plan segment code. The compact form H4754004000 refers to the same normalized contract, plan, and segment shown on this page.
Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.