2019 Summary of Benefits: Presbyterian MediCare PPO Plan 1, Plan 2 with Rx
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- Iris Willis
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1 2019 Summary of Benefits: Presbyterian MediCare PPO Plan 1, Plan 2 with Rx This is a summary of health and drug services covered by Presbyterian MediCare PPO January 1, 2019 to December 31, To enroll in Presbyterian MediCare PPO: You must be entitled to Medicare Part A and enrolled in Medicare Part B. You cannot have permanent kidney failure. Exceptions may apply. You must live in New Mexico. This plan covers services from either in-network or out-of-network providers, as long as the services are covered benefits and are medically necessary. If you choose to receive care from out-of-network providers, there will likely be a higher out-of-pocket cost for you. Y0055_MPC _Accepted_M_
2 2019 Summary of Benefits Presbyterian MediCare PPO Monthly Plan Premium (You must also continue to pay your Medicare Part B premium.) Plan 1 In-Network Plan 2 In-Network $89 $175 Does not include prescription drug coverage Includes prescription drug coverage Out-of- Network Deductible Maximum Annual Out-of-Pocket Responsibility (This is the most you pay in a calendar year for covered medical and hospital services. It does not include prescription drugs.) $6,700 $6,700 $10,000 Combined In- and Outof-Network Maximum Inpatient Hospital Care* (per admission) Days 1 5 Additional Days $325 per day per admit $325 per day per admit $500 per day per admit Outpatient Surgery* $325 $325 Doctor Visits (no referral required) Primary Care Specialists Video Visits $15 $50 $15 $50 $35 $60 $35 Preventive Care $35 Emergency Care (worldwide) (This copay is waived if admitted to the hospital.) $90 $90 $90 Urgently Needed Services In-network Outside of United States $15 $90 $15 $90 $65 $90 * Prior authorization required.
3 2019 Summary of Benefits Presbyterian MediCare PPO Plan 1 In-Network Plan 2 In-Network Out-of- Network Diagnostic Services/Labs/ Imaging Lab services Diagnostic tests and procedures Outpatient x-rays Diagnostic radiology service* (such as CT, MRA, MRI, PET scans) $15 $300 $15 $300 Hearing Services (does not go toward maximum out-of-pocket responsibility) Hearing exam Hearing aid $45 $699 - $999 $45 $699 - $999 $60 Not covered Vision Services (annual routine exam and diagnosis and treatment of diseases and conditions of eye) Eyeglasses or contact lenses after cataract surgery for first visit of the year; specialist copay thereafter $60 25% Dental Services Medicare covered Routine $50 Not covered $50 Not covered $60 Not covered Mental Health Services Inpatient visit (Days 1-5)* Additional days Outpatient group therapy visit Outpatient individual therapy visit $325 per day per admission $40 $40 $325 per day per admission $40 $40 $500 per day per admission 50% 50% Skilled Nursing Facility (SNF)* Days 1-20 Days (Our plan covers up to 100 days in a SNF.) per day $95 per day per day $95 per day per day $150 per day * Prior authorization required.
4 2019 Summary of Benefits Presbyterian MediCare PPO Plan 1 In-Network Plan 2 In-Network Out-of- Network Rehabilitation Services Cardiac and Pulmonary rehab (limited to 36 visits/year) Occupational, Physical, and Speech and Language therapy visits $25 $25 $35 $35 Ambulance (ground and air) $250 $250 $250 Routine Transportation Not covered Not covered Not covered Medicare Part B Drugs* Chemotherapy Drugs and other drugs administered by a medical professional Purchased at a retail pharmacy Foot Care (podiatry services) Foot exams and treatment (Medicare covered) 15% 15% $10 $10 $60 Medical Equipment/Supplies* Durable Medical Equipment (e.g., wheelchairs, oxygen) Prosthetics (e.g., braces, artificial limbs) 25% 25% Wellness Programs (e.g., fitness) Acupuncture (limited to 25 visits/year) Chiropractic To correct subluxation Routine (limited to 25 visits/year) Silver Sneakers Fitness Program is included. For participating locations visit $20 $20 $60 $20 $20 $20 $20 $60 $60 Home Health Care* * Prior authorization required.
5 2019 Summary of Benefits Presbyterian MediCare PPO Prescription drug coverage is a part of Plan 2. Prescription Drug Deductibles All Tiers Plan 2 $325 Initial Coverage Initial coverage limit $3,820; includes what both you and your plan pay Coverage Gap "Donut Hole" Catastrophic Coverage Part D Covered Drugs 30-day supply 90-day mail order (preferred) Plan 2 Plan 2 Tier 1: Preferred Generic Tier 2: Non- Preferred Generic Tier 3: Preferred Brand Tier 4: Non- Preferred Brand Tier 5: Specialty Drugs $4 $8 $10 $20 $45 $ $95 $285 25% NA 37% generic 25% brand applies to all tiers $3.40 or 5% for generics (whichever is greater) $8.50 or 5% for brand names (whichever is greater) You stay in this stage for the rest of the year. Catastrophic coverage begins after your out-of-pocket costs = $5,100
6 Financial assistance As a Medicare beneficiary, you may qualify for money-saving programs based on your income to help you pay your plan premiums and drug costs. Extra Help / Low-Income Subsidy (LIS) If you qualify for Extra Help, also called Low-Income Subsidy (LIS), your plan premium and drug costs will be reduced. Premium Your premium will be reduced based on the LIS level you qualify for. The table below has the premium you will pay if you qualify for the 100% LIS level. Monthly Premium (LIS Level 100%) MediCare PPO Plan 2 $ Prescription drugs If you qualify for Low-Income Subsidy (LIS), your prescription drug deductible and coverage gap (also known as the donut hole) in your drug coverage is eliminated. You also pay reduced copays for your Part D drugs. See the table below. Depending on your Low-Income Subsidy Level For generic drugs (including brand drugs treated as generic) you pay: copayment; or $1.25 copayment; or $3.40 copayment; or 15% See if you qualify for LIS For all other drugs you pay: copayment; or $3.80 copayment; or $8.50 copayment; or 15% Qualifying income levels for To qualify, your annual income and resources / assets need to be at or below the following: Single Married Monthly Income 1 : $1, Monthly Income 1 : $ 2, Resources / Assets 2 : $14, Resources / Assets 2 : $ 28, Income limits may change in The house you live in, the car you drive, life insurance policies, and burial plots do not count toward the resource / asset limit. Contact Social Security for other income / resource exclusions.
7 Medicaid and Other Medicare Savings Programs (MSP) Those who qualify for Extra Help may also qualify for Medicare Savings Programs that help pay Part A and/or Part B premiums. Medicaid programs may also lower your copays, depending on the level for which you qualify. FIND OUT IF YOU QUALIFY FOR ASSISTANCE Presbyterian offers a personal service that helps you find out if you qualify for these money-saving programs. A trusted partner since 2006, My Advocate, helps you apply for Extra Help / Low-Income Subsidy and Medicare Savings Programs. Call My Advocate at You also have the option to contact: Medicare ( ), 24 hours a day, seven days a week (TTY ) Social Security, (TTY ) NM State Human Services Department, (TTY )
8 For more information about Presbyterian Medicare Advantage plans, please call us at the phone numbers below or visit us at Presbyterian Medicare Sales Consultants (505) or (TTY 711) Presbyterian Customer Service Center (for members) (505) or (TTY 711) Hours: 8 a.m. to 8 p.m., seven days a week from October 1 through March 31 and Monday to Friday (except holidays) from April 1 through September 30. You can see our plan s provider and pharmacy directory if you visit our website at www. phs.org/medicare and select Providers at the top of the page. For coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, seven days a week. TTY users should call ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call (505) or (TTY 711). To learn how we safeguard your Protected Health Information and your rights, call us at (505) or (TTY 711) or visit and select Privacy Notice at the bottom of the page. Out-of-network/non-contracted providers are under no obligation to treat Presbyterian Senior Care (HMO) and Presbyterian MediCare PPO members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. To get a complete list of services we cover, contact the plan or please refer to the Evidence of Coverage. You may easily download a copy of the Evidence of Coverage from our website, and select For Members at the top of the page. You may also request a copy by calling customer service. Presbyterian MediCare PPO is a Medicare Advantage plan with a Medicare contract. Enrollment in the plan depends on contract renewal. This information is not a complete description of benefits. Call (505) or (TTY 711) for more information.
9 Multi-Language Interpreter Services English Spanish ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call , (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al , (TTY: 711). Navajo D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti go Diné Bizaad, saad bee 1k1 1n7da 1wo d66, t 11 jiik eh, 47 n1 h0l=, koj8 h0d77lnih , (TTY: 711). Vietnamese German CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số , (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: , (TTY: 711). Chinese 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 , (TTY: 711) ملحوظة: إذا كنت تتحدث اذكراللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم: Arabic رقم هاتف الصم والبكم ) ). Korean Tagalog- Filipino Japanese French Italian Russian Hindi 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 , (TTY: 711) 번으로전화해주십시오. PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa , (TTY: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le , (ATS: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero , (TTY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните , (телетайп: 711). ध य न द : दद आप द द ब लत त आपक ललए म फत म भय षय स य तय स वय ए उपलब ध , (TTY: 711) पर क ल कर توجه: اگر به زبان فارسی گفتگو می کنيد تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. Farsi با ) (TTY: تماس بگيريد. Thai เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร , (TTY: 711). Y0055_MPC071602_rev1_Accepted_
10 Notice of Nondiscrimination and Accessibility Discrimination is Against the Law Presbyterian Healthcare Services complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Presbyterian Healthcare Services does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Presbyterian Healthcare Services: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact the Presbyterian Customer Service Center at (505) , , TTY 711. If you believe that Presbyterian Healthcare Services has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance. You can file a grievance in person, or by mail, fax, or . If you need help filing a grievance, the Privacy Officer and Civil Rights Coordinator is available to help you. Presbyterian Privacy Officer and Civil Rights Coordinator P.O. Box Albuquerque, NM Phone: , TTY: 711 Fax (505) info@phs.org. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C Phone: , (TDD) Complaint forms are available at Y0055_MPC081640_rev1_Accepted_
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