Prescription Drug Coverage
Part D drug coverage is included with Presbyterian Senior Care (HMO) Plan 2 and Plan 3, Presbyterian UltraFlex (HMO-POS), Presbyterian Dual Plus (HMO D-SNP), and Presbyterian MediCare PPO Plan 2. There is NO drug coverage in either HMO Plan 1 or PPO Plan 1.
Search the Formulary drug list to see if your drugs are covered. We explain what to do if a drug is not covered, how to request an exception, and describe Specialty Pharmacy Network Providers. Formulary (Drug List)
Learn the options to help you get the most out of your medications by identifying and resolving any medication-related issues. This program is provided at no cost to our members and is not considered a benefit. Medication Therapy Management (MTM) Program
Find pharmacies by name or location. Note that some medications are required to be obtained through a designated specialty pharmacy provider.
Online Presbyterian Senior Care (HMO) Provider Directory Online Presbyterian UltraFlex (HMO-POS) Provider Directory Online Presbyterian Dual Plus (HMO D-SNP) Provider Directory Online Presbyterian MediCare PPO Provider Directory
Drug Formulary Safety
If you're considering prescription drug coverage with one of our Medicare Advantage plans, you'll be happy to know that we use a drug formulary developed by a team of health care providers. They regularly look at the safety and cost of drugs, selecting the most effective and cost-effective drug in each class. It's one of the most important ways we safeguard your health and help keep drug costs affordable.
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 Presbyterian Senior Care (HMO) Plans 2 and 3, Presbyterian Dual Plus (HMO D-SNP), and Presbyterian MediCare PPO Plan 2. 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.
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.
Find out if you qualify for the Medicare Savings Program Services
or call:
1-800-MEDICARE or
(TTY ) 24 hours a day, 7 days a weekThe Social Security Office at
(TTY ) 7 am to 7 pm, Monday through FridayNM State Human Services Department (HSD) at
(TTY )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 policy on the CMS Web site.
CMS Best Available Evidence Policy information
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 (
) (toll free), or (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.