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2017 Presbyterian Medicare Advantage Formularies

This formulary is a list of covered drugs selected by Presbyterian Senior Care (HMO) and Presbyterian MediCare PPO in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Presbyterian Senior Care (HMO) and Presbyterian MediCare PPO will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Presbyterian Senior Care (HMO) and Presbyterian MediCare PPO network pharmacy, and other plan rules are followed.

 

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:


  • Prior Authorization: Presbyterian Senior Care (HMO) and Presbyterian MediCare PPO requires you or your physician to get prior authorization for certain drugs.

  • Quantity Limits: For certain drugs, Presbyterian Senior Care (HMO) and Presbyterian MediCare PPO limits the amount of the drug that Presbyterian Senior Care (HMO) and Presbyterian MediCare PPO will cover.

  • Step Therapy: In some cases, Presbyterian Senior Care (HMO) and Presbyterian MediCare PPO requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

  • Can the formulary (drug list) change?

    Presbyterian Medicare Advantage Formulary may change during the year. Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when the safety or effectiveness of a drug is released or you are can save additional money. All changes will be listed in following Notice of Formulary Changes.



    What if my drug is not on the formulary? How to request an exception:

    If your drug is not included in this formulary (list of covered drugs), you should contact Customer Service available from 8 am to 8 pm daily at 505-923-6060 or 1-800-797-5343 (TTY 711) to ask if your drug is covered.

    You can also ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

    You can ask us to cover your drug even if it is not on our formulary.

    You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

    You can ask us to provide a higher level of coverage for your drug if this drug is not on Tier 5, the specialty tier. For example, if your drug is usually considered a Highest Tier Name drug, you can ask us to cover it as a Lower Tier Name instead. This would lower the co-payment amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.

     

    To request an exception, you or your appointed representative should call Presbyterian Senior Care Appeals

    505-923-6060 or 1-800-797-5343 (TTY 711)
    Hours: 8:00 am to 8:00 pm daily

    Your doctor can also fax a request to:
    Form Requesting Prior Authorization for Drugs

    505-923-5540

    - or -

    You may also submit your grievance electronically


    Exception requests may be mailed to:

    PHP Pharmacy Department
    Presbyterian Senior Care
    P.O. Box 27489
    Albuquerque, NM 87125-7489



    Specialty Pharmacy Network Providers

    If administered through a doctor’s office some medications are required to be obtained through the designated specialty network provider and delivered to the facility or doctor’s office that you have chosen.

    Specialty Pharmacy & Medical Drugs Coverage
     

​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. || Presbyterian Dual Plus is an HMO Special Needs Plan (SNP) with a Medicare Contract and a contract with the New Mexico State Department of Human Services Department Medicaid program. Enrollment in Presbyterian Dual Plus (HMO SNP) 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.

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Last Updated: 09/30/2016