2018 Presbyterian Senior Care Plan 3 with Rx (HMO) H3204-7-0 in NM from Presbyterian | HealthPocket
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Presbyterian Senior Care Plan 3 with Rx (HMO)

$1,524/mo
Summary of BenefitsCovered Drugs

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Zip Code87121
Applicant10/18/1983 Male
Coverage Start10/19/2018
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Benefits & Coverage

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderPresbyterian
Plan IDH3204-7-0
Plan Year2018
CMS Rating
Plan TypeHMO
Annual Deductible$250.00
What To Know About This Plan
  • This plan has health and drug coverage
  • This plan is available for 2019. see plan
Why We Like This Plan
  • has both Health and Drug Coverage

Costs and Other Important Information

Plan Year2018
Optional Supplemental BenefitsNo
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$3,000 In-network
Other health plan deductibles?No
Health Plan Deductible$0
Monthly Drug Plan Premium$67.70
Monthly Health Plan Premium$59.30

Benefits

SERVICECOST
Inpatient hospital coverage$225 for days 1 through 5
$0 for days 6 through 90
Outpatient hospital coverage$80-225 per visit
Doctor visitsPrimary:
$5 per visit
Specialist:
$40 per visit
Preventive care$0 copay
Emergency care/Urgent careEmergency:
$80 per visit (always covered)
Urgent care:
$5-65 per visit (always covered)
Diagnostic procedures/lab services/imagingDiagnostic tests and procedures:
$0 copay
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$250
Outpatient x-rays:
$0 copay
Mental health services$225 for days 1 through 5
$0 for days 6 through 90
Outpatient group therapy visit with a psychiatrist:
$0 copay
Outpatient individual therapy visit with a psychiatrist:
$0 copay
Outpatient group therapy visit:
$0 copay
Outpatient individual therapy visit:
$0 copay
Skilled Nursing Facility$0 for days 1 through 20
$75 for days 21 through 100
Rehabilitation servicesOccupational therapy visit:
$20
Physical therapy and speech and language therapy visit:
$20
Ambulance$200
TransportationNot covered
Foot care (podiatry services)Foot exams and treatment:
$0 copay
Routine foot care:
Not covered
Medical equipment/suppliesDurable medical equipment (e.g., wheelchairs, oxygen):
20% per item
Prosthetics (e.g., braces, artificial limbs):
20% per item
Diabetes supplies:
$0-10 per item
Wellness programs (e.g., fitness, nursing hotline)Covered
Medicare Part B drugsChemotherapy:
0-5%
Other Part B drugs:
$10 or 0-5%

Coverage Area for Presbyterian Senior Care 3 with Rx (HMO)

StateNew Mexico
CountyBernalillo

All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred GenericNot offereds$4 copay$4 copay
Tier 2: Non-Preferred GenericNot offered$10 copay$10 copay
Tier 3: Preferred Brand NameNot offered$45 copay$45 copay
Tier 4: Non-Preferred Brand NameNot offered$95 copay$95 copay
Tier 5: Specialty TierNot offered28% coinsurance28% coinsurance
60 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred GenericNot offered$8 copay$8 copay
Tier 2: Non-Preferred GenericNot offered$20 copay$20 copay
Tier 3: Preferred Brand NameNot offered$90 copay$90 copay
Tier 4: Non-Preferred Brand NameNot offered$190 copay$190 copay
Tier 5: Specialty Tier
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred GenericNot offered$12 copay$8 copay
Tier 2: Non-Preferred GenericNot offered$30 copay$20 copay
Tier 3: Preferred Brand NameNot offered$135 copay$112.5 copay
Tier 4: Non-Preferred Brand NameNot offered$285 copay$285 copay
Tier 5: Specialty Tier

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Colorectal cancer screening
Annual flu vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Adult BMI assessment

Managing Chronic Conditions

Special needs plan care managementNot Rated
Care for older adults – medication reviewNot Rated
Care for older adults – functional status assessmentNot Rated
Care for older adults – Pain screeningNot Rated
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Controlling blood pressure
Rheumatoid arthritis management
Reducing the risk of falling
Plan all-cause readmissions

Member Experience with Health Plan

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan
Care Coordination

Member Complaints, and Changes in Health Plan's Performance

Complaints about the health plan
Members choosing to leave the health plan
Beneficiary access and performance problems
Health plan quality improvement

Health Plan Customer Service

Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability - Medical

Drug Plan Customer Service

Call center – foreign language interpreter and TTY/TDD availability - Drugs
Appeals auto-forward
Appeals upheld

Member Complaints, and Changes in Drug Plan's Performance

Complaints about the drug plan
Members choosing to leave the drug plan
Beneficiary access and performance problems
Drug plan quality improvement

Member Experience with Drug Plan

Rating of drug plan
Getting needed prescription drugs

Drug Pricing and Patient Safety

MPF Price Accuracy
High risk medication
Part D medication adherence for diabetes
Part D medication adherence for hypertension
Part D medication adherence for cholesterol
Medication Therapy Management program completion rate

Physicians that accept Presbyterian Senior Care 3 with Rx (HMO) for New Mexico

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Dozeman, Lynn
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Tam, Adela
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Candelaria, Delfino
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Buxton, Benjamin
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Loughrey, Galen
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Peachey, Marilyn
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Fetner, Jean
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Guerrero-pezzano, Tatyana
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Montoya, Andrea
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Miller, Frederick
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Shelley, Brian
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Kassicieh, Samir
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Hockin, Benjamin
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Gallegos-macias, Angela
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Ponce, Liana
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Jacobsohn, Vanessa Cook
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Jansen, Shari
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Gurule, Monica
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Barnes, Jesse
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Buckels, Wendy
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Lynn Dozeman, MD
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  • Phone Number
    (505) 831-2534
  • Office Locations
    6900 Gonzales Rd Sw
    Albuquerque, NM 87121
6900 Gonzales Rd Sw Albuquerque NM, 87121
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