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2012 Presbyterian MediCare PPO

 

2012 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. It may cost more to get care from out-of-network providers except in an emergency.

This plan requires no referrals and offers no-charge preventive services including annual physical, vision, and hearing exams.

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 or out-of-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. Individuals must have both Medicare Part A and Part B to enroll.

Benefits (Premiums and Cost-sharing)

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). Please refer to the following Summary of Benefits:

stopIMPORTANT: 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 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.

2012 Presbyterian MediCare PPO Formulary (Drug List), En Español 

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.

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 The Customer Service Center 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 2012 Presbyterian MediCare PPO Formulary (Drug List), En Español  See below for the co-payment amount for each type of drug.

There is no deductible for prescription drugs.

Drug Tier

Retail Pharmacy Co-payment (30-day supply)

Mail-Order Co-payment (90-day supply)

Tier 1 - Preferred Generic

$5

$10

Tier 2 - Preferred Brand

$40

$100

Tier 3 - Non-Preferred

$75

$225

Tier 4 - Specialty Pharmaceuticals

30%

N/A

 

If you are enrolled in Presbyterian MediCare PPO Plan 2 with Rx, or Presbyterian MediCare PPO Plan 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 $2,930.

Once your total drug costs reach $2,930, 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 $4,700 out-of-pocket.

After you have paid $4,700 out-of-pocket, you will generally pay the greater of:

  • $2.60 for generic or a preferred brand drug
  • $6.50 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 $2,930.

After your total drug costs (the amount you paid, plus the amount Presbyterian MediCare PPO has paid) reach $2,930, 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 $2,930, you pay 100% of your prescription drug costs up until your yearly out-of-pocket drug costs reach $4,550.

After your yearly out-of-pocket drug costs reach $4,550, you will pay the greater of:

  • $2.600 for generic or a preferred brand drug and
  • $6.50 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 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 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. This 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

2012 Evidence of Coverage/Member Handbook

Please use the links below to view the 2012 Presbyterian MediCare PPO Evidence of Coverage/Member Handbook.

2012 Presbyterian MediCare PPO Plan 1. En Español 

2012 Presbyterian MediCare PPO Plan 2. En Español 

2012 Presbyterian MediCare PPO Plan 3. En Español 

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:

  • 2012 Presbyterian MediCare PPO Conditions and Limitations
  • Part D Transition [Pending CMS Approval]
  • Out-of-Network Coverage
  • Potential for Contract Termination
  • Grievances, Appeals and Exceptions Plan 1,   En Español [Spanish Pending CMS approval]
  • Grievances, Appeals and Exceptions Plan 2,   En Español [Spanish Pending CMS approval]
  • Grievances, Appeals and Exceptions Plan 3,   En Español [Spanish Pending CMS approval]
  •  
  • Information on the number of appeals and grievances filed by members of this plan, are available by calling The Customer Service Center:
  • For help or information, please call the Presbyterian Customer Service Center:

November 15 through February 14 - The Presbyterian Customer Service Center has representatives available to assist you Monday through Sunday, including holidays, from 8:00 a.m. to 8:00 p.m.  Messages left will be responded to within one business day.  Please call (505) 923-6060 or 1-800-797-5343, or the Hearing Impaired Access Line at 1-888-625-8818.   Business Hours: February 15 through October 14 - The Presbyterian Customer Service Center has representatives available to assist you Monday through Friday from 8:00 a.m. to 8:00 p.m. The PresbyterianCustomerServiceCenter uses a voice response system to assist you Saturday, Sunday, and holidays from 8:00 a.m. to 8:00 p.m., also e-mail us info@phs.org.

  • Presbyterian MediCare PPO Rights, Responsibilities and Disenrollment.
  • This information is available in other languages and formats, including Spanish. Please call the Customer Service Center at (505) 923-6060 or 1-800-797-5343, or the TTY number 1-888-625-8818, if you need assistance.
  • Esta información está disponible en otros idiomas y formatos, incluso español. Sírvase llamar al Centro de Servicio al Cliente al (505) 923-6060 o 1-800-797-5343, o al número para personas con problemas auditivos al 1-888-625-8818, si necesita ayuda.
  • Low Income Subsidy Premium Information, En Español
  •  
  • Presbyterian MediCare PPO 2012 Enrollment Instructions and Enrollment Form, En Español 

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to (100) percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more infirmation about this Extra Help, contact your local Security office or call 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days per week. TTY users should call 1-877-486-2048.

If you would like to enroll in a Presbyterian MediCare PPO plan or require additional information, please call the Presbyterian MediCare PPO Sales Team at (505)923-8458 or toll-free at 1-800-347-4766, Monday through Friday from 8 a.m. to 5 p.m. TTY users please call 1-888-625-6429.

Calls are directed to licensed sales representatives.

You can also e-mail our sales team 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 download and print the Presbyterian MediCare PPO 2012 Enrollment Instructions and Enrollment Form, En Español  and mail the completed Enrollment Form to:

 

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

You may also fax a completed Enrollment Form to Presbyterian MediCare PPO at (505) 923-5385.

Privacy Notice En Español

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 En Español or would like more information about our privacy practices, please call Jackson R. Ellison, VP Corporate Compliance and Chief Privacy Officer Presbyterian Healthcare Services. He can be reached at (505) 923-8544 or by e-mail at jellison2@phs.org.


Fraud and Abuse En Español


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. En Español

 

 

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