2008 Presbyterian Medicare PPO

2008 Presbyterian MediCare PPO (Preferred Provider Organization) offers more benefits than Original Medicare and allows you to be seen by any Medicare-approved practitioner or provider, anywhere.

It requires no referrals and offers no-charge preventive services including an annual physical exam, as well as an annual vision and hearing exam.

Service Area

Presbyterian MediCare PPO is available in all counties in New Mexico.

Eligibility

Anyone living in New Mexico with Medicare Part A and Part B may apply, including those under age 65 entitled to Medicare on the basis of Social Security Disability Benefits, those who have elected Hospice coverage under Original Medicare, and those having End Stage Renal Disease and meeting all other eligibility guidelines.

Presbyterian MediCare PPO provides reimbursement for all covered benefits regardless of whether they are received in-network, with the exception of emergency or urgent care. Your out-of-pocket costs may be higher if you use out-of-network practitioners and providers. Members must continue to pay Medicare premium(s).

Benefits (Premiums and Cost-sharing)

Please refer to our 2008 Presbyterian MediCare PPO Summaries of Benefits for premium and cost sharing information on Presbyterian MediCare PPO Plan 1 (no prescription drug coverage), Plan 2 with Rx and Plan 3 with Rx (both with prescription drug coverage).

Our Provider and Pharmacy Network

Please refer to our 2008 Presbyterian MediCare PPO Provider and Pharmacy Directory for a list of in-network providers and pharmacies. The Directory lists both the types and locations of providers and pharmacies.

IMPORTANT: Presbyterian MediCare PPO Plan 1 does not have prescription drug coverage. The pharmacies listed in the Directory only apply to members of Presbyterian MediCare PPO Plan 2 with Rx (prescription drug coverage) and Plan 3 with Rx (prescription drug coverage).

For members of Presbyterian MediCare PPO Plan 2 with Rx and Plan 3 with Rx, Presbyterian wants you to know that Presbyterian Insurance Co. has contracts with pharmacies that equal or exceed the Centers for Medicare and Medicaid Services' (CMS) requirements for pharmacy access in the service area.

2008 Presbyterian MediCare PPO Formulary (Drug List)

IMPORTANT: This Formulary is only for use by members with Presbyterian MediCare PPO Plan 2 with Rx and Plan 3 with Rx, the two Presbyterian MediCare PPO plans with Medicare prescription drug coverage. For more information about the Presbyterian MediCare PPO Formulary, please click on one of the links below:

• Current Formulary information updated monthly

Formulary and tiering exceptions process

How much will I pay for Presbyterian MediCare PPO Covered Drugs?

If you qualified for extra help with your drug costs, your costs for your drugs may be different than those described below. Please refer to your Evidence of Coverage or call Member Services to find out what your costs are.

The amount you pay depends on which drug tier your drug is in under our plan and whether you fill your prescription at a preferred network pharmacy. (You can find out which drug tier your drug is in by looking in the formulary.) See below for the co-payment amount for each type of drug.

If you are enrolled in Presbyterian MediCare PPO Plan 2 with Rx, you will pay the co-payment amount above for your drugs until your total drug costs (the amount you paid, including the deductible, plus the amount Presbyterian MediCare PPO has paid) reach $2,510.

Once your total drug costs reach $2,510, there is a gap in your coverage.

This means you have to pay the full amount for your drugs.

You pay the full amount until you have paid $4,050 out-of-pocket.

After you have paid $4,050 out-of-pocket, you will generally pay the greater of:

• $2.15 for generic or a preferred brand drug and $5.35 for all other drugs, or
• 5% co-insurance.

If you are enrolled in Presbyterian MediCare PPO Plan 3 with Rx, you will pay the co-payment amount above for your drugs until your total drugs costs (the amount you paid, plus the amount Presbyterian MediCare PPO has paid) reach $2,510.

After your total drug costs (the amount you paid, plus the amount Presbyterian MediCare PPO has paid) reach $2,510, you pay:

• $5 for a one-month (30 day) supply of Preferred Generic Drug.
• $15 for a three-month (90-day) supply of Preferred Generic Drugs.

For all other covered drugs and after the total yearly drug costs (paid by both you and your plan) reach $2,510, you pay 100% of your prescription drug costs up until your yearly out-of-pocket drug costs reach $4,050.

After your yearly out-of-pocket drug costs reach $4,050, you will pay the greater of:

• $2.25 for generic or a preferred brand drug and
• $5.60 for all other drugs, or
• 5% co-insurance

You can ask Presbyterian MediCare PPO to make an exception to your drug's tier placement.

See the section, "How do I request an exception to the Presbyterian MediCare PPO List of Covered Drugs?" for information about how to request an exception.

• Presbyterian MediCare PPO must provide at least 60 days notice to CMS, State Pharmaceutical Assistance Programs, authorized prescribers, and network pharmacies before removing a prescription drug from the Formulary or making any other changes to the Formulary, or cost-sharing status of a covered prescription drug. Presbyterian MediCare PPO will provide at least 60 days notice to affected members prior to the effective date of a Formulary change.

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call:

• 1-800-Medicare (1-800-633-4227), TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week, or
• The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-877-325-0778, or
• Your State Medicaid Office

Quality Assurance Program

We created the Medical Management Program to monitor the quality of care you receive and to provide services that are cost effective. The program helps your providers and practitioners make sure you stay healthy and get the care you need.

We use the following processes to assist you and your practitioner:

• Care Coordination to assist with obtaining necessary healthcare services
• Case Management for members who are in the hospital and for members who have complex healthcare needs
• Review of hospital and outpatient bills to be sure that services are billed correctly (retrospective review)
• Looking at services to be sure that members are receiving the care that is needed (looking for under- or over-utilization)
  • Pharmacy and Therapeutics Committee
  • Preferred Drug List
  • Medication Management Program
  • Pharmacy Benefit Manager
  • Medical/Pharmacy Exception Process

2008 Evidence of Coverage/Member Handbook

Please use the links below to view the 2008 Presbyterian MediCare PPO Evidence of Coverage/Member Handbook.

The Evidence of Coverage/Member Handbook explains benefits, rights, responsibilities, and other important information for new and current members of Presbyterian MediCare PPO, including information about:

• Conditions and Limitations
• Part D Transition
• Out-of-Network Coverage
• Potential for Contract Termination
• Grievances, Appeals and Exceptions
  Information on the number of appeals and grievances filed by members of this plan, are available by calling Member Services at (505) 923-6060 or 1-800-797-5343/TDD 1-888-625-8818
• Rights and Responsibilities and Disenrollment

To receive information in Spanish about the content of this document, please call Member Services, Monday through Sunday from 8 a.m. to 8 p.m. at (505) 923-6060 or 1-800-797-5343, or the Hearing-impaired number at 1-888-625-8818.

Para recibir información en español sobre el contenido de este documento, por favor llame al Departamento de Servicios a la Membresía, de lunes a domingo de 8 a.m. a 8 p.m., al (505) 923-6060 o 1-800-797-5343, o al número para personas con problemas auditivos al 1-888-625-8818.

• Low Income Subsidy Premium Information

Enrollment Instructions and Enrollment Form

If you qualify for extra help with your Medicare prescription drug plan costs, your premium and costs will be lower. When you join a Presbyterian MediCare PPO, Medicare will tell us how much extra help you are getting. Then we will let you know the amount you will pay. If you aren't getting this extra help, you can see if you qualify by calling:

• 1-800-MEDICARE (1-800-633-4227)
  • TTY/TDD users should call 1-877-486-2048, (24 hours a day/7 days a week), or
• Your State Medicaid Office, or
• The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday
  • TTY/TDD users should call 1-800-325-0778

Presbyterian MediCare PPO Enrollment Form

If you would like to enroll in a Presbyterian MediCare PPO plan or require additional information, please call Presbyterian MediCare Sales at (505) 923-8458 or toll-free at 1-800-347-4766, TDD Hearing-impaired Access Line 1-888-625-6429. You can contact our Sales Department via e-mail at jdecker@phs.org.

Medicare Beneficiaries may enroll in Presbyterian MediCare PPO plans through the Centers for Medicare and Medicaid services Online Enrollment Center.

You can also print and complete the Presbyterian MediCare PPO Enrollment Form (.pdf) and mail it to:

Presbyterian MediCare PPO
P.O. Box 25361
Albuquerque, NM 87125-9762

You may also fax a completed enrollment form (.pdf) to Presbyterian MediCare PPO at (505) 923-8432.

Privacy Notice

At Presbyterian, we are serious about protecting your privacy. We encourage you to read this Notice, and we ask that you keep a copy for your records. If you have questions about this Privacy Notice or would like more information about our privacy practices, please call us at (505) 923-8544.

Fraud and Abuse

Presbyterian Health Plan and Presbyterian Insurance Company's Special Investigative Unit (SIU) is responsible for the detection, investigation, and reporting of potential fraud and abuse activity. We are required to cooperate with regulatory and law-enforcement agencies in reporting any activity that appears to be suspicious in nature. According to the law, any information that we have concerning such matters must be turned over to the appropriate governmental agencies. Find out more.

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