Presbyterian MediCare PPO Plan 3 with Rx is a Medicare Advantage plan from Presbyterian Healthcare Services that's available in Union County, New Mexico. It is a Preferred Provider Organization (PPO) option, with prescription drug coverage, for people with Medicare Part A and Part B benefits.
You can reach Presbyterian Healthcare Services directly at (800)347-4766 or (800)659-8331 for TTY users.
About PPO Plans with Part D
PPO health insurance allows you to choose your own primary care doctor, specialists and other healthcare providers. If you're on a budget you can lower your out-of-pocket costs by using the plan's provider network.
IMPORTANT: Unlike Original Medicare, your out-of-pocket expenses are capped with this plan. As a result, you won't be vulnerable to excessive medical bills due to an accident or a critical illness.
CRITICAL: The prescription drug coverage included with Presbyterian MediCare PPO Plan 3 with Rx has its own deductible and co-pays. If you have prescriptions, make sure your drugs are covered at a favorable price before you join this plan.
Monthly Premium and Deductibles
The premium on this plan is $166.60 per month. That includes your prescription drugs, as well. Plus, you must continue to pay your monthly Medicare Part B premium. Co-payments and/or co-insurances also apply with most healthcare services, except preventive care mandated by CMS (see H3206-002 Summary of Benefits below).
Although the health plan itself does not have a deductible, the prescription drug plan does. It's $0.00 per year. That means you have first dollar coverage.
IMPORTANT: When evaluating this plan, look past the monthly premium. Identify the costs of the healthcare services you use most. Only then will you uncover the plan's value for your personal situation.
Maximum Out-of-Pocket (MOOP) Limit for Parts A & B
Unlike Original Medicare, Medicare Advantage plans must set an annual Maximum Out-of-Pocket limit on inpatient and outpatient healthcare services. The Presbyterian MediCare PPO Plan 3 with Rx plan MOOP is $3,401 . Once you reach this amount of spending on your co-payments, all of your Medicare Part A and Part B services will be covered at no additional charge.
Plans can set their MOOP at a voluntary level of $0 to $3,400 (for in-network services) or a mandatory $3,401 to $6,700 (in-network). Combined totals for in-network and out-of-network are generally higher.
NOTE: MOOP does not include what you spend on monthly premiums. It also does not apply to your prescription drugs or Part D deductible.
CRITICAL: It is important to evaluate the combined annual MA/MAPD premiums and MOOP versus what you might expect to pay for a Medigap plan in Union County. Some Medicare Supplements offer less overall financial risk than Medicare Advantage.
In this section we show you the quality rating for this plan. Each year the Centers for Medicare and Medicaid Services (CMS) rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories. We do not recommend joining a plan with an overall rating less than 3.0. The following marks will give you an idea of the level of care you will receive if you join this Presbyterian Healthcare Services plan.
|2016 Overall Rating|
|Part C Summary Rating|
|Part D Summary Rating|
|Staying Healthy: Screenings, Tests, Vaccines|
|Managing Chronic (Long Term) Conditions|
|Member Experience with Health Plan|
|Complaints and Changes in Plans Performance|
|Health Plan Customer Service|
|Drug Plan Customer Service|
|Complaints and Changes in the Drug Plan|
|Member Experience with the Drug Plan|
|Drug Safety and Accuracy of Drug Pricing|
Part D Prescription Drug Benefits
This plan includes Medicare Part D prescription drug benefits. If you have regular prescriptions, it's critical that you evaluate your costs using the plan's formulary.
|Annual Rx Deductible:||0.00|
|Initial Coverage Limit (ICL):||$3,310|
|Plan's Pharmacy Page:||http://www.phs.org/Medicare|
|Plan's Formulary Page:||http://www.phs.org/medicare|
|Plan Offers an Online Pharmacy:||No|
Here's what you'll pay at the pharmacy if you join this plan:
IMPORTANT: Once you and your plan provider have spent $3,310 on covered drugs (combined amount plus your deductible), you will be in the donut hole coverage gap. In this phase, unless the plan offers additional coverage, you will pay 45% for brand-name drugs and 58% on generic drugs. This Presbyterian Healthcare Services plan does provide additional coverage through the gap.
NOTE: Medicare Advantage plans that include prescription drug coverage (MAPDs) are treated like Medicare Part D plans. Members at higher income levels are subject to the Income Related Monthly Adjustment Amount (IRMAA). In some situations, IRMAA can be appealed. You will need to show SSA evidence of a qualifying event and provide proof of your lower income.
Summary of Benefits (H3206-002)
In this section we outline high-level information about the plan's co-payment and co-insurance costs for inpatient, outpatient, preventive care, transportation and other healthcare services. For complete details, download the Presbyterian MediCare PPO Plan 3 with Rx Summary of Benefits.
Outpatient Care and Services
All outpatient health care services (Medicare Part B benefits) have their own co-payment or co-insurance costs. Here's how this plan charges for the basics.
|Primary Care Doctor:||20% co-insurance|
|Physician Specialist:||$35 co-payment|
|Occupational Therapist:||$15 co-payment|
|Physical Therapist:||$15 co-payment|
|Speech Terapist:||$15 co-payment|
|Podiatrist:||You pay nothing|
Lab and Diagnostic Services
Lab and diagnostic services have co-payment or co-insurance costs. Some plans offer these services at no cost, but most do not.
|Medicare-covered Diagnostic Procedures/Tests:|
|Medicare-covered Lab Services:|
|Medicare-covered Diagnostic Radiological Services:||$250 co-payment|
|Medicare-covered Therapeutic Radiological Services|
|Medicare-covered X-Ray Services|
Urgent Care and Emergency Services
Urgent care and emergency room services (Medicare Part B benefits) have co-payment or co-insurance costs. Some plans waive these costs if you are admitted as an inpatient within a specified amount of time. Also, plans are not required to offer emergency care worldwide.
|Urgent Care:||$10 to $65 co-payment|
|Emergency Care:||$75 co-payment |
Co-insurance waived if admitted within 24 Hours
Medicare Preventive Care
Presbyterian MediCare PPO Plan 3 with Rx covers preventive services, as required by law under Medicare Part B, including:
- Abdominal aortic aneurysm screening
- Alcohol misuse counseling
- Bone mass measurement
- Breast cancer screening (mammogram)
- Cardiovascular disease (behavioral therapy)
- Cardiovascular screenings
- Cervical and vaginal cancer screening
- Colorectal cancer screenings
- Depression screening
- Diabetes screenings
- HIV screening
- Medical nutrition therapy services
- Obesity screening and counseling
- Prostate cancer screenings (PSA)
- Sexually transmitted infections screening and counseling
- Tobacco use cessation counseling
- Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
- "Welcome to Medicare" preventive visit
- Yearly "Wellness" visit
All preventive healthcare services are provided at no cost to the beneficiary. Any additional preventative services approved by Medicare during the contract year will be covered.
Inpatient Care and Services
When you are admitted into a hospital or skilled nursing facility you will make copayments based on benefit periods. A benefit period begins when you are admitted and ends after not receiving inpatient care for 60 days in a row. If you are admitted again after a benefit period has ended a new benefit period begins.
You are required to pay an inpatient deductible for each benefit period. There are no limits on the the number of benefit periods. Here's how this plan charges:
- Day 1 to 3 you pay $225 per day
- See the Summary of Benefits for additional copayment periods.
You pay nothing for hospice care from a Medicare-approved (certified) hospice facility. You may have to pay some of the cost for drugs and respite care.
Presbyterian MediCare PPO Plan 3 with Rx is available to beneficiaries living in Amistad, Capulin, Clayton, Des Moines, Folsom, Gladstone, Grenville, Sedan, and all other areas of Union County, New Mexico.
For assistance 24 hours a day, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048 or visit www.medicare.gov
Tips and Disclaimers
The Medicare Advantage plan data on MedicareWire.com comes directly from Medicare.gov and CMS.gov and is subject to change. The Centers for Medicare and Medicaid Services has neither reviewed nor endorsed the information on this site.
The benefit information provided on this page is a brief summary only, not a complete description. Limitations, co-payments, and restrictions may apply. For more information contact the plan directly at (800)347-4766 or (800)659-8331 for TTY users.
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This Medicare Part C information is maintained by David Bynon and was last updated on .