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2018 Presbyterian Advantage Medicare Plans

​​

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

If you would like to view 2019 plans, click here


2018 Presbyterian MediCare PPO Plans​​

Presbyterian MediCare PPO Plans
Plan 1 PPO No Drug Plan Plan 2 PPO with Drug Plan
Monthly Premium
Monthly Premium
$95
$163
Summary of Benefits
Summary of Benefits View Summary of Benefits View Summary of Benefits
Evidence of Coverage
Evidence of Coverage View Evidence of Coverage View Evidence of Coverage
Includes Part D Prescription Drugs
Includes Part D Prescription Drugs No Yes
Out-of-Pocket Maximum
Out-of-Pocket Maximum
In-Network:
$6,700
Out-of-Network:
$10,000
In-Network:
$6,700
Out-of-Network:
$10,000

Office Visits & Tests

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

Emergency, Urgent, & Video Visits

Video Visits
Video Visits
In-Network:
$0
Out-of-Network:
$35
In-Network:
$0
Out-of-Network:
$35
Urgent Care
Urgent Care
In-Network:
$15
Out-of-Network:
$65
In-Network:
$15
Out-of-Network:
$65
Emergency Care (Waived if admitted)
Emergency Care (Waived if admitted)
In-Network:
$80
Out-of-Network:
$80
In-Network:
$80
Out-of-Network:
$80
Emergency Medical Transportation (Ambulance)
Emergency Medical Transportation (Ambulance)
In-Network:
$200
Out-of-Network:
$200
In-Network:
$200
Out-of-Network:
$200

Inpatient & Outpatient Coverage

Inpatient Hospital Care
Inpatient Hospital Care
In-Network:
$320 per day
for days 1-5
$0 after day 5
per admit
Out-of-Network:
$500 per day
for days 1-5
$0 after day 5
per admit
In-Network:
$320 per day
for days 1-5
$0 after day 5
per admit
Out-of-Network:
$500 per day
for days 1-5
$0 after day 5
per admit
Outpatient Surgery
Outpatient Surgery
In-Network:
$320
Out-of-Network:
20%
In-Network:
$320
Out-of-Network:
20%
Outpatient Hospital Facility
Outpatient Hospital Facility
In-Network:
$320
Out-of-Network:
20%
In-Network:
$320
Out-of-Network:
20%
Inpatient Behavioral Health Care
Inpatient Behavioral Health Care
In-Network:
$320 per day
for days 1-5
$0 after day 5
per admit
Out-of-Network:
$500 per day
for days 1-5
$0 after day 5
per admit
In-Network:
$320 per day
for days 1-5
$0 after day 5
per admit
Out-of-Network:
$500 per day
for days 1-5
$0 after day 5
per admit
Partial Hospitalization - Psychiatric Treatment
Partial Hospitalization - Psychiatric Treatment
In-Network:
$40
Out-of-Network:
50%
In-Network:
$40
Out-of-Network:
50%
Psychiatric Services - Individual
Psychiatric Services - Individual
In-Network:
$40
Out-of-Network:
50%
In-Network:
$40
Out-of-Network:
50%
Behavioral Health Specialty Services - Individual
Behavioral Health Specialty Services - Individual
In-Network:
$40
Out-of-Network:
50%
In-Network:
$40
Out-of-Network:
50%
Outpatient Substance Abuse Care - Individual
Outpatient Substance Abuse Care - Individual
In-Network:
$40
Out-of-Network:
50%
In-Network:
$40
Out-of-Network:
50%
Chemotherapy and other drugs administered by a medical professional
Chemotherapy and other drugs administered by a medical professional
In-Network:
15%
Out-of-Network:
20%
In-Network:
15%
Out-of-Network:
20%
Part B - Drugs purchased at a retail pharmacy
Part B - Drugs purchased at a retail pharmacy
In-Network:
$10
Out-of-Network:
20%
In-Network:
$10
Out-of-Network:
20%

Home Health & Rehabilitation

Home Health Care
Home Health Care
In-Network:
$0
Out-of-Network:
$0
In-Network:
$0
Out-of-Network:
$0
Cardiac & Pulmonary Rehabilitation Services
Cardiac & Pulmonary Rehabilitation Services
In-Network:
$0
Out-of-Network:
$35
In-Network:
$0
Out-of-Network:
$35
Physical Therapy, Occupational Therapy, Speech Therapy
Physical Therapy, Occupational Therapy, Speech Therapy
In-Network:
$25
Out-of-Network:
$35
In-Network:
$25
Out-of-Network:
$35
Durable Medical Equipment & Prosthetic Devices
Durable Medical Equipment & Prosthetic Devices
In-Network:
20%
Out-of-Network:
25%
In-Network:
20%
Out-of-Network:
25%
Skilled Nursing Facility
Skilled Nursing Facility
In-Network
Days in Facility:
1- 20: $0 per day
21-100: $95 per day
 
Out-of-Network
Days in Facility:
1- 20: $0 per day
21-100: $150 per day
 
In-Network
Days in Facility:
1- 20: $0 per day
21-100: $95 per day
 
Out-of-Network
Days in Facility:
1- 20: $0 per day
21-100: $150 per day

Additional Coverage

Fitness Programs
Fitness Programs Silver Sneakers® Silver Sneakers®
Hearing Aid (does not go toward maximum out-of-pocket responsibility)
Hearing Aid (does not go toward maximum out-of-pocket responsibility)

​Not Available

​Not Available

Podiatry Services
Podiatry Services
In-Network:
$0
Out-of-Network:
$60
In-Network:
$0
Out-of-Network:
$60
Vision Services
Vision Services
In-Network:
$0 - $50
Out-of-Network:
$60
In-Network:
$0 - $50
Out-of-Network:
$60

Part D Prescription Drug Coverage

Deductible
Deductible
N/A
$375
Tier 1: Preferred Generic 30 Days - Retail / 90 Days - Preferred Mail Order
Tier 1: Preferred Generic 30 Days - Retail / 90 Days - Preferred Mail Order
N/A
$4
$8
Tier 2: Generic 30 Days - Retail / 90 Days - Preferred Mail Order
Tier 2: Generic 30 Days - Retail / 90 Days - Preferred Mail Order
N/A
$10
$20
Tier 3: Preferred Brand 30 Days - Retail / 90 Days - Preferred Mail Order
Tier 3: Preferred Brand 30 Days - Retail / 90 Days - Preferred Mail Order
N/A
$45
$112.50
Tier 4: Non-Preferred Drug 30 Days - Retail / 90 Days - Preferred Mail Order
Tier 4: Non-Preferred Drug 30 Days - Retail / 90 Days - Preferred Mail Order
N/A
$95
$285
Tier 5: Specialty 30 Days - Retail
Tier 5: Specialty 30 Days - Retail
N/A
25%
Initial Coverage Ends and Gap Begins at:
Initial Coverage Ends and Gap Begins at:
N/A
$3,750
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
Generic through Gap - Member Pays
N/A
44%
Brand through Gap - Member Pays
Brand through Gap - Member Pays
N/A
35%
Gap Coverage Ends and Catastrophic Begins at:
Gap Coverage Ends and Catastrophic Begins at:
N/A
$5,000
Catastrophic Coverage begins after your out-of-pocket costs meet the Gap Coverage Limit above and continues through year end.
Generic Catastrophic - Member Pays
Generic Catastrophic - Member Pays
N/A
Greater of $3.35
or 5%
Brand Catastrophic - Member Pays
Brand Catastrophic - Member Pays
N/A
Greater of $8.35
or 5%

Presbyterian Drug List

For more information about covered drugs, review our drug list.

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.

 

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Last Updated: 09/30/2017