Skip to Content

2016 Prescription Drug Benefits

Drug coverage is a part of both Presbyterian Senior Care (HMO) Plans 2 and 3 and Presbyterian MediCare PPO Plans 2 and 3.

The drug coverage is identical for all plans except in one area: Gap Coverage. If a member selects Plan 3 for either the HMO or PPO plans, most generic drugs are covered during the Coverage Gap. You can find which drugs have Gap Coverage in your formulary. If a member selects Plan 2 for either the HMO or the PPO, the member pays 65% of the cost of the generic drug.

Please review the Drug Coverage below. Remember, Plan 1 does not include drug coverage.

Part D Prescription Drug Coverage - Plans 2 & 3 Member Pays
Deductible $0
Tier 1: Preferred Generic
30 Days - Retail / 90 Days - Mail Order
$4 / $8
Tier 2: Generic
30 Days - Retail / 90 Days - Mail Order
$10 / $20
Tier 3: Preferred Brand
30 Days - Retail / 90 Days - Mail Order
$45 / $112.50
Tier 4: Non-Preferred Brand
30 Days - Retail / 90 Days - Mail Order
$95 / $285
Tier 5: Specialty
30 Days - Retail
33%
Initial Coverage Limit (Includes what both you and your plan pay) $3,310
Gap Coverage (the Donut Hole) begins when the Initial Coverage Limit is reached
Generic through Gap - Plan 2 Member Pays 65%
Generic through Gap - Plan 3 Member Pays $10 / $00
Brand through Gap - Plan 2 or Plan 3 Member Pays 45%
Gap Coverage Ends when : $4,850
Catastrophic Coverage begins after your out-of-pocket costs meet the Gap Coverage Limit above and continues through year end.
Generic Catastrophic Greater of $2.95 or 5%
Brand Catastrophic Greater of $7.40 or 5%

Understanding Part D When You're First Eligible

Joining a health plan that includes Part D prescription drug coverage is voluntary. However, if you don't sign up for Part D when you first become eligible and then enroll later, you may have to pay a late enrollment penalty — a monthly cost added to your future Part D premiums. Remember, Part D drug coverage is a part of both Presbyterian Senior Care (HMO) Plans 2 and 3 and Presbyterian MediCare PPO Plans 2 and 3. If you enroll 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 to Help to Pay for your Prescription Drugs

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.

    The Medicare Savings Program (MSP) helps you pay for Medicare Part A and/or Part B premiums with 4 kinds of programs if you qualify if you are below the resource and income limits. Medicare Savings Program Services

     

Extra Help, also called Low-Income Subsidy (LIS), reduces 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. Source: Social Security Administration

To see the what you monthly plan premium for Plan 2 and Plan 3 if you get extra help, choose your desired plan

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)


CMS created the best available evidence (BAE) policy in 2006. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate in CMS's systems. View the CMS Best Available Evidence Policy information on the CMS Web site.

Transition Policy for Part D Drugs

Presbyterian Medicare Advantage’s transition policy addresses those situations in which members may not be aware of the medications on the formulary or unsure of what is covered or unfamiliar with the formulary exception process. This policy meets the immediate needs of our valued enrollees and allows them sufficient time to work with their prescribing provider to switch to a therapeutically equivalent formulary medication or complete the formulary exception process.

Your Options Upon Disenrollment

If you leave your Medicare Advantage plan, you have other options for obtaining prescription drug coverage:

Medicare Prescription Drug Plan (PDP). A PDP is a stand-alone drug plan that can be added to Original Medicare coverage or other Medicare health plan that does not include Part D. To enroll in a PDP in your area, you must be entitled to Medicare benefits under Part A and/or currently enrolled in Part B, and reside in the service area of the plan.

Medicare Advantage Prescription Drug Plan (MA-PD). You can join another Medicare Advantage plan with prescription drug coverage if it is available in your area, accepting new members, and if you meet the plan's eligibility requirements. If you choose to join another Medicare Advantage plan that offers prescription drug coverage, then you must obtain your Medicare prescription drug coverage through that Medicare Advantage plan.

For more information on joining a Medicare Advantage plan in your area, contact 1-800-MEDICARE (1-800-633-4227) (toll free), or 1-877-486-2048 (toll-free TTY for the hearing/speech impaired), 24 hours a day, seven days a week. Or visit the Medicare Web site. Note: If you go without a Medicare drug plan or other creditable prescription drug coverage for a continuous period of 63 days or more, you may have to pay a late enrollment penalty when you enroll in a Medicare Part D plan later.

 

​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 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.

​ ​​​​​

Y0055_MPC091696_Approved_10312016
Last Updated: 09/30/2016