2022 Presbyterian MediCare PPO Plan 2 with Rx (PPO)

Presbyterian MediCare PPO Plan 2 with Rx (PPO) H3206-001 is a 2022 Medicare Advantage Plan or Part-C by Presbyterian Insurance Company, Inc available to residents in New Mexico. This plan includes additional prescription drug (Part-D) coverage. The Presbyterian MediCare PPO Plan 2 with Rx (PPO) has a monthly premium of $188.00 and has an in-network maximum out-of-pocket limit of $6,700 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,700 out-of-pocket. This can be a extremely nice safety net.

Presbyterian MediCare PPO Plan 2 with Rx (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Presbyterian Insurance Company, Inc works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Presbyterian MediCare PPO Plan 2 with Rx (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Presbyterian Insurance Company, Inc and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Presbyterian Insurance Company, Inc except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

2022 Presbyterian Insurance Company, Inc Medicare Advantage Plan Costs

Presbyterian MediCare PPO Plan 2 with Rx (PPO) Part-C Premium

Presbyterian Insurance Company, Inc charges a $119.10 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H3206-001 Part-D Deductible and Premium

Presbyterian MediCare PPO Plan 2 with Rx (PPO) has a monthly drug premium of $68.90 and a $430.00 drug deductible. This Presbyterian Insurance Company, Inc plan offers a $68.90 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Presbyterian Insurance Company, Inc above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $68.90 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Presbyterian Insurance Company, Inc Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Presbyterian Insurance Company, Inc plan does not offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Presbyterian MediCare PPO Plan 2 with Rx (PPO) medicare insurance offers a $34.60 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $43.20 for 75% low income subsidy $51.70 for 50% and $60.30 for 25%.

H3206-001 Formulary or Drug Coverage

Presbyterian MediCare PPO Plan 2 with Rx (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Presbyterian MediCare PPO Plan 2 with Rx (PPO) H3206-001 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	NA	$4
Tier 2	NA	$10
Tier 3	NA	$45
Tier 4	NA	$95
Tier 5	NA	25%

*Initial Coverage Phase and 30 day supply

2021 Presbyterian MediCare PPO Plan 2 with Rx (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

---

Additional Benefits

No

---

Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

---

Deductible

$0

---

Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	20% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$300 copay
Diagnostic tests and procedures	20% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0 copay
Lab services	20% coinsurance (Out-of-Network)
Lab services	$0 copay
Outpatient x-rays	20% coinsurance (Out-of-Network)
Outpatient x-rays	$20 copay

---

Doctor Visits

Primary	$35 copay per visit (Out-of-Network)
Primary	$15 copay per visit
Specialist	$60 copay per visit (Out-of-Network)
Specialist	$50 copay per visit

---

Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$15-65 copay per visit (always covered)

---

Foot Care (podiatry services)

Foot exams and treatment	$0 copay
Foot exams and treatment	$60 copay (Out-of-Network)
Routine foot care	Not covered

---

Ground Ambulance

$250 copay
$250 copay (Out-of-Network)

---

Hearing

Fitting/evaluation	$60 copay (Out-of-Network)
Fitting/evaluation	$0 copay
Hearing aids	$699-999 copay
Hearing aids	$699-999 copay (Out-of-Network)
Hearing exam	$0 copay
Hearing exam	$60 copay (Out-of-Network)

---

Inpatient Hospital Coverage

$500 per day for days 1 through 5 $0 per day for days 6 through 90 (Out-of-Network)
$325 per day for days 1 through 5 $0 per day for days 6 through 90

---

Medical Equipment/Supplies

Diabetes supplies	25% coinsurance per item (Out-of-Network)
Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	25% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	25% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

---

Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	20% coinsurance (Out-of-Network)
Other Part B drugs	$10 copay or 20% coinsurance
Other Part B drugs	20% coinsurance (Out-of-Network)

---

Mental Health Services

Inpatient hospital - psychiatric	$325 per day for days 1 through 5 $0 per day for days 6 through 90
Inpatient hospital - psychiatric	$500 per day for days 1 through 5 $0 per day for days 6 through 90 (Out-of-Network)
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit	50% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient group therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay

---

MOOP

$10,000 In and Out-of-network $6,700 In-network

---

Option

No

---

Optional supplemental benefits

Yes

---

Outpatient Hospital Coverage

$325 copay per visit
20% coinsurance per visit (Out-of-Network)

---

Package #1

Deductible
Monthly Premium	$19.00

---

Preventive Care

$0 copay
$35 copay (Out-of-Network)

---

Preventive Dental

Cleaning	$0 copay
Cleaning	$0 copay (Out-of-Network)
Dental x-ray(s)	$0 copay
Dental x-ray(s)	$0 copay (Out-of-Network)
Fluoride treatment	$0 copay
Fluoride treatment	$0 copay (Out-of-Network)
Oral exam	$0 copay
Oral exam	$0 copay (Out-of-Network)

---

Rehabilitation Services

Occupational therapy visit	$25 copay
Occupational therapy visit	$35 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$35 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$25 copay

---

Skilled Nursing Facility

$0 per day for days 1 through 20 $150 per day for days 21 through 100 (Out-of-Network)
$0 per day for days 1 through 20 $95 per day for days 21 through 100

---

Transportation

Not covered

---

Vision

Contact lenses	Not covered
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	Not covered
Other	Not covered
Routine eye exam	$0 copay
Routine eye exam	$60 copay (Out-of-Network)
Upgrades	Not covered

---

Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Presbyterian MediCare PPO Plan 2 with Rx (PPO) H3206

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Presbyterian MediCare PPO Plan 2 with Rx (PPO) Plans Performance

Health Plan Customer Service Rating for Presbyterian MediCare PPO Plan 2 with Rx (PPO)

Presbyterian MediCare PPO Plan 2 with Rx (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Presbyterian MediCare PPO Plan 2 with Rx (PPO)

(Click county to compare all available Advantage plans)

Go to top

Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.