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2016 Presbyterian Advantage Medicare Plans

The following plans are available to New Mexico Medicare Beneficiaries with a primary residence in Bernalillo, Cibola, Rio Arriba, Sandoval, Santa Fe, Socorro, Torrance, and Valencia counties.

If you would like to view 2017 plans, click here


2016 Plans With Prescription Drug Coverage

Presbyterian Senior Care (HMO) Plans Presbyterian MediCare PPO Plans
Plan 2 HMO with Drug Plan Plan 3 HMO with Drug Plan Plan 2 PPO with Drug Plan Plan 3 PPO with Drug Plan
Monthly Premium $0
$87
$132
 
$166.60
    ​
Summary of Benefits View Summary of Benefits View Summary of Benefits View Summary of Benefits View Summary of Benefits
Evidence of Coverage View Evidence of Coverage View Evidence of Coverage View Evidence of Coverage View Evidence of Coverage
Includes Part D Prescription Drugs Yes Yes Yes Yes
Out-of-Pocket Maximum $3,400 $2,500
In-Network:
     $4,000
Out-of-Network:
     $7,500
In-Network:
     $3,401
Out-of-Network:
     $7,500

Office Visits & Tests

Preventive Care, Screening & Immunizations $0 $0
In-Network:
      $0
Out-of-Network:
     $35
In-Network:
      $0
Out-of-Network:
     $35
Doctor's Office Visit - Primary $5 $5
In-Network:
     $10
Out-of-Network:
     $35
In-Network:
     $10
Out-of-Network:
     $35
Doctor's Office Visit - Specialist $50 $35
In-Network:
     $50
Out-of-Network:
     $60
In-Network:
     $35
Out-of-Network:
     $60
Chiropractic $20 $20
In-Network:
     $20
Out-of-Network:
     $60
In-Network:
     $20
Out-of-Network:
     $60
Acupuncture (20 visits per year)
$20
$15
In-Network:
     $15
Out-of-Network:
     $60
In-Network:
     $15
Out-of-Network:
     $60
Diagnostic Tests - Procedures, Tests & Lab Services $0 $0
In-Network:
      $0
Out-of-Network:
     10% - 20%
In-Network:
      $0
Out-of-Network:
     10% - 20%
Imaging - X-Ray, Therapeutic Radiology Services $0 $0
In-Network:
      $0
Out-of-Network:
     10% - 20%
In-Network:
      $0
Out-of-Network:
     10% - 20%
MRI/MRA, CT Scan, PET Scan $300 $250
In-Network:
      $300
Out-of-Network:
      20%
In-Network:
      $250
Out-of-Network:
      20%

Emergency, Urgent, & Video Visits

Video Visits $0 $0
In-Network:
      $0
Out-of-Network:
     $35
In-Network:
      $0
Out-of-Network:
     $35
Urgent Care
 
In-Network:
      $5
Out-of-Network:
     $65
 
 
In-Network:
      $5
Out-of-Network:
     $65
 
In-Network:
     $10
Out-of-Network:
     $65
In-Network:
     $10
Out-of-Network:
     $65
Emergency Care (Waived if admitted) $75 $75
In-Network:
     $75
Out-of-Network:
     $75
In-Network:
     $75
Out-of-Network:
     $75
Emergency Medical Transportation (Ambulance) $100 $100
In-Network:
     $150
Out-of-Network:
     $150
In-Network:
     $150
Out-of-Network:
     $150

Inpatient & Outpatient Coverage

Inpatient Hospital Care
$325 per day
for days 1-3
$0 after day 3
per admit
$225 per day
for days 1-3
$0 after day 3
per admit
In-Network:
     $300 per day
     for days 1-3
    $0 after day 3
     per admit
Out-of-Network:
     $1,000/per admit
In-Network:
     $225 per day
     for days 1-3
     $0 after day 3
     per admit
Out-of-Network:
     $1,000/per admit
Outpatient Surgery
$325
$225
In-Network:
     $300
Out-of-Network:
      20%
In-Network:
     $225
Out-of-Network:
      20%
Outpatient Hospital Facility
$325
$225
In-Network:
     $300
Out-of-Network:
      20%
In-Network:
     $225
Out-of-Network:
      20%
Inpatient Behavioral Health Care
$325 per day
for days 1-3
$0 after day 3
per admit
$225 per day
for days 1-3
$0 after day 3
per admit
In-Network:
     $300 per day
     for days 1-3
    $0 after day 3
     per admit
Out-of-Network:
     $1,000/per admit
In-Network:
     $225 per day
     for days 1-3
     $0 after day 3
     per admit
Out-of-Network:
     $1,000/per admit
Partial Hospitalization - Psychiatric Treatment $50 $35
In-Network:
     $40
Out-of-Network:
      50%
In-Network:
     $35
Out-of-Network:
      50%
Psychiatric Services - Individual $0 $0
In-Network:
     $40
Out-of-Network:
      50%
In-Network:
     $35
Out-of-Network:
      50%
Behavioral Health Specialty Services - Individual $0 $0
In-Network:
     $40
Out-of-Network:
      50%
In-Network:
     $35
Out-of-Network:
      50%
Outpatient Substance Abuse Care - Individual $0 $0
In-Network:
     $40
Out-of-Network:
      50%
In-Network:
     $35
Out-of-Network:
      50%

Home Health & Rehabilitation

Home Health Care $0 $0
In-Network:
     $0
Out-of-Network:
     $0
In-Network:
     $0
Out-of-Network:
     $0
Cardiac & Pulmonary Rehabilitation Services $0 $0
In-Network:
      $0
Out-of-Network:
     $35
In-Network:
      $0
Out-of-Network:
     $35
Physical Therapy, Occupational Therapy, Speech Therapy
$15
$10
In-Network:
     $20
Out-of-Network:
     $35
In-Network:
     $15
Out-of-Network:
     $35
Durable Medical Equipment & Prosthetic Devices 20% 10%
In-Network:
      20%
Out-of-Network:
     25%
In-Network:
      10%
Out-of-Network:
     25%
Skilled Nursing Facility
Days in Facility:
  1- 20: $0 per day
21-100: $65 per day
Days in Facility:
  1- 20: $0 per day
21-100: $35 per day
In-Network
  Days in Facility:
  1- 20: $0 per day
21-100: $40 per day
 
Out-of-Network
  Days in Facility:
  1- 20: $0 per day
21-100: $60 per day
In-Network
  Days in Facility:
  1- 20: $0 per day
21-100: $40 per day
 
Out-of-Network
  Days in Facility:
  1- 20: $0 per day
21-100: $60 per day

Additional Coverage

Fitness Programs Silver Sneakers® Silver Sneakers® Silver Sneakers® Silver Sneakers®
Podiatry Services $0 $0
In-Network:
      $0
Out-of-Network:
     $60
In-Network:
      $0
Out-of-Network:
     $60
Vision Services Range $0-$50 Range $0-$35
In-Network:
     $0 - $50
Out-of-Network:
     $60
In-Network:
     $0 - $35
Out-of-Network:
     $60

Part D Prescription Drug Coverage

Deductible $0 $0 $0 $0
Tier 1: Preferred Generic 30 Days - Retail 90 Days - Mail Order
$4
$8
$4
$8
$4
$8
$4
$8
Tier 2: Generic 30 Days - Retail 90 Days - Mail Order
$10
$20
$10
$20
$10
$20
$10
$20
Tier 3: Preferred Brand 30 Days - Retail 90 Days - Mail Order
$45
$112.50
$45
$112.50
$45
$112.50
$45
$112.50
Tier 4: Non-Preferred Brand 30 Days - Retail 90 Days - Mail Order
$95
$285
$95
$285
$95
$285
$95
$285
Tier 5: Specialty 30 Days - Retail 33% 33% 33% 33%
Initial Coverage Ends and Gap Begins at: $3,310 $3,310 $3,310 $3,310
Initial Coverage Limit includes the total drug costs that both you and the plan pay for calendar year. Then Gap Coverage (the Donut Hole) begins.
Generic through Gap - Member Pays
58%
$10
$20
58%
$10
$20
Brand through Gap - Member Pays 45% 45% 45% 45%
Gap Coverage Ends and Catastrophic Begins at: $4,850 $4,850 $4,850 $4,850
Catastrophic Coverage begins after your out-of-pocket costs meet the Gap Coverage Limit above and continues through year end.
Generic Catastrophic - Member Pays
Greater of $2.95
or 5%
Greater of $2.95
or 5%
Greater of $2.95
or 5%
Greater of $2.95
or 5%
Brand Catastrophic - Member Pays
Greater of $7.40
or 5%
Greater of $7.40
or 5%
Greater of $7.40
or 5%
Greater of $7.40
or 5%

2016 Plans Without Prescription Drug Coverage

Presbyterian Senior Care (HMO) Plans Presbyterian MediCare PPO Plans
Plan 1 HMO No Drug Plan Plan 1 PPO No Drug Plan
Monthly Premium

$0​​

 
$85
Summary of Benefits View Summary of Benefits View Summary of Benefits
Evidence of Coverage View Evidence of Coverage View Evidence of Coverage
Includes Part D Prescription Drugs No No
Out-of-Pocket Maximum $2,500
In-Network:
     $4,000
Out-of-Network:
     $7,500

Office Visits & Tests

Preventive Care, Screening & Immunizations $0
In-Network:
      $0
Out-of-Network:
     $35
Doctor's Office Visit - Primary $5
In-Network:
     $10
Out-of-Network:
     $35
Doctor's Office Visit - Specialist $35
In-Network:
     $50
Out-of-Network:
     $60
Chiropractic $20
In-Network:
     $20
Out-of-Network:
     $60
Acupuncture (20 visits per year) $15
In-Network:
     $15
Out-of-Network:
     $60
Diagnostic Tests - Procedures, Tests & Lab Services $0
In-Network:
      $0
Out-of-Network:
     10% - 20%
Imaging - X-Ray, Therapeutic Radiology Services $0
In-Network:
      $0
Out-of-Network:
     10% - 20%
MRI/MRA, CT Scan, PET Scan $250
In-Network:
      $300
Out-of-Network:
      20%

Emergency, Urgent, & Video Visits

Video Visits $0
In-Network:
      $0
Out-of-Network:
     $35
Urgent Care
In-Network:
      $5
Out-of-Network:
     $65
In-Network:
     $10
Out-of-Network:
     $65
Emergency Care (Waived if admitted) $75
In-Network:
     $75
Out-of-Network:
     $75
Emergency Medical Transportation (Ambulance) $100
In-Network:
     $150
Out-of-Network:
     $150

Inpatient & Outpatient Coverage

Inpatient Hospital Care
$225 per day
for days 1-3
$0 after day 3
per admit
In-Network:
     $300 per day
     for days 1-3
    $0 after day 3
     per admit
Out-of-Network:
     $1,000/per admit
Outpatient Surgery $225
In-Network:
     $300
Out-of-Network:
      20%
Outpatient Hospital Facility $225
In-Network:
     $300
Out-of-Network:
      20%
Inpatient Behavioral Health Care
$225 per day
for days 1-3
$0 after day 3
per admit
In-Network:
     $300 per day
     for days 1-3
    $0 after day 3
     per admit
Out-of-Network:
     $1,000/per admit
Partial Hospitalization - Psychiatric Treatment $35
In-Network:
     $40
Out-of-Network:
      50%
Psychiatric Services - Individual $0
In-Network:
     $40
Out-of-Network:
      50%
Behavioral Health Specialty Services - Individual $0
In-Network:
     $40
Out-of-Network:
      50%
Outpatient Substance Abuse Care - Individual $0
In-Network:
     $40
Out-of-Network:
      50%

Home Health & Rehabilitation

Home Health Care $0
In-Network:
     $0
Out-of-Network:
     $0
Cardiac & Pulmonary Rehabilitation Services $0
In-Network:
      $0
Out-of-Network:
     $35
Physical Therapy, Occupational Therapy, Speech Therapy
$10
In-Network:
     $20
Out-of-Network:
     $35
Durable Medical Equipment & Prosthetic Devices 10%
In-Network:
      20%
Out-of-Network:
     25%
Skilled Nursing Facility
Days in Facility:
  1- 20: $0 per day
21-100: $35 per day
In-Network
  Days in Facility:
  1- 20: $0 per day
21-100: $40 per day
 
Out-of-Network
  Days in Facility:
  1- 20: $0 per day
21-100: $60 per day
 

Additional Coverage

Fitness Programs Silver Sneakers® Silver Sneakers®
Podiatry Services $0
In-Network:
      $0
Out-of-Network:
     $60
Vision Services Range $0 to $35
In-Network:
     $0 - $50
Out-of-Network:
     $60

For more information about covered drugs, review our

If you are enrolled in a Medicare Advantage or Medicare Advantage prescription drug plan like one of the Presbyterian Medicare Advantage plans, you may not enroll in a stand-alone Part D prescription drug plan, unless you disenroll from your Medicare Advantage plan.


Financial Assistance for Medicare Beneficiaries

As a Medicare beneficiary, you may qualify for money-saving programs based on your income to help you pay your plan premiums and drug copays.

Extra Help, also called Low-Income Subsidy (LIS), lowers your plan premium and drug copays, as well as eliminates the coverage gap (the donut hole). You must be on a plan that includes prescription drug coverage to qualify. Note: Levels are reviewed annually by the Social Security Administration and may change each year.

Review the monthly plan premiums for Plan 2 and Plan 3 to understand the reductions if you qualify for Extra Help:

 

    The Medicare Savings Program (MSP) helps you pay for Medicare Part A and/or Part B premiums with 4 kinds of programs.

To see if you qualify for Extra Help go to Medicare Savings Program Services

or call:

1-800-MEDICARE or 1-800-633-4227 (TTY 1-877-486-2048) 24 hours a day, 7 days a week

The Social Security Office at 1-800-772-1213 (TTY 1-800-325-0778) 7 am to 7 pm, Monday through Friday

NM State Human Services Department (HSD) at 1-888-997-2583 (TTY 1-800-659-8331)


Appeals, Grievances and Exceptions

You have the right to make a complaint if you have concerns or problems related to your coverage or care. Appeals and grievances are the two different types of complaints you can make. You can also ask us to make an exception to our formulary coverage rules. There are several types of exceptions that you can ask us to make.

To view Medical Appeals and Grievances, click here
To request a Pharmacy exception, click here

Star Ratings

Each year, all Medicare health and prescription drug programs are rated by the Medicare Program based on the plan's quality and performance.

 

​Presbyterian Senior Care (HMO) is an HMO plan with a Medicare contract. Presbyterian MediCare PPO is a PPO plan with a Medicare contract. Enrollment in Presbyterian Senior Care (HMO) or Presbyterian MediCare PPO depends on contract renewal. || This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, co-payments and/or co-insurance may change on January 1 of each year. || The physicians and other medical professionals in our provider network participate through contractual arrangements. A provider may leave the network because of retirement, relocation, or other reasons before your next enrollment date. || The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. || You must continue to pay your Medicare Part B premium. || ​Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

​ ​​​​​

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Last Updated: 09/30/2016