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2016 Presbyterian Advantage Medicare Plans

The following plans are available to all New Mexico Medicare beneficiaries.

If you would like to view 2017 plans, click here


2016 Presbyterian MediCare PPO Plans

Presbyterian MediCare PPO Plans
Plan 2 PPO with Drug Plan Plan 3 PPO with Drug Plan Plan 1 PPO No Drug Plan
Monthly Premium
$132
 
$166.60
    ​
$85
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
Includes Part D Prescription Drugs Yes Yes No
Out-of-Pocket Maximum
In-Network:
     $4,000
Out-of-Network:
     $7,500
In-Network:
     $3,401
Out-of-Network:
     $7,500
In-Network:
     $4,000
Out-of-Network:
     $7,500

Office Visits & Tests

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

Emergency, Urgent, & Video Visits

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

Inpatient & Outpatient Coverage

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

Home Health & Rehabilitation

Home Health Care
In-Network:
     $0
Out-of-Network:
     $0
In-Network:
     $0
Out-of-Network:
     $0
In-Network:
     $0
Out-of-Network:
     $0
Cardiac & Pulmonary Rehabilitation Services
In-Network:
      $0
Out-of-Network:
     $35
In-Network:
      $0
Out-of-Network:
     $35
In-Network:
      $0
Out-of-Network:
     $35
Physical Therapy, Occupational Therapy, Speech Therapy
In-Network:
     $20
Out-of-Network:
     $35
In-Network:
     $15
Out-of-Network:
     $35
In-Network:
     $20
Out-of-Network:
     $35
Durable Medical Equipment & Prosthetic Devices
In-Network:
      20%
Out-of-Network:
     25%
In-Network:
      10%
Out-of-Network:
     25%
In-Network:
      20%
Out-of-Network:
     25%
Skilled Nursing Facility
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
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®
Podiatry Services
In-Network:
      $0
Out-of-Network:
     $60
In-Network:
      $0
Out-of-Network:
     $60
In-Network:
      $0
Out-of-Network:
     $60
Vision Services
In-Network:
     $0 - $50
Out-of-Network:
     $60
In-Network:
     $0 - $35
Out-of-Network:
     $60
In-Network:
     $0 - $50
Out-of-Network:
     $60

Part D Prescription Drug Coverage

Deductible $0 $0 N/A
Tier 1: Preferred Generic 30 Days - Retail 90 Days - Mail Order
$4
$8
$4
$8
N/A
Tier 2: Generic 30 Days - Retail 90 Days - Mail Order
$10
$20
$10
$20
N/A
Tier 3: Preferred Brand 30 Days - Retail 90 Days - Mail Order
$45
$112.50
$45
$112.50
N/A
Tier 4: Non-Preferred Brand 30 Days - Retail 90 Days - Mail Order
$95
$285
$95
$285
N/A
Tier 5: Specialty 30 Days - Retail 33% 33% N/A
Initial Coverage Ends and Gap Begins at: $3,310 $3,310 N/A
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
N/A
Brand through Gap - Member Pays 45% 45% N/A
Gap Coverage Ends and Catastrophic Begins at: $4,850 $4,850 N/A
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%
N/A
Brand Catastrophic - Member Pays
Greater of $7.40
or 5%
Greater of $7.40
or 5%
N/A

For more information about our 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

The Medicare Program rates health and prescription drug plans each year, based on a plan's quality and performance.

 

​Presbyterian MediCare PPO is a PPO plan with a Medicare contract. Enrollment in 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