Presbyterian MediCare PPO Plan 1 (PPO)
H3206 - 003 - 0
(2.5 / 5)
Presbyterian MediCare PPO Plan 1 (PPO) is a Medicare Advantage (Part C) Plan by Presbyterian Insurance Company, Inc..
This page features plan details for 2024 Presbyterian MediCare PPO Plan 1 (PPO) H3206 – 003 – 0 available in State of New Mexico.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Presbyterian MediCare PPO Plan 1 (PPO) is offered in the following locations.
Plan Overview
Presbyterian MediCare PPO Plan 1 (PPO) offers the following coverage and cost-sharing.
| Insurer: | Presbyterian Insurance Company, Inc. |
| Health Plan Deductible: | $0.00 |
| MOOP: | $10,250 In and Out-of-network $6,950 In-network |
| Drugs Covered: | No |
Ready to sign up for Presbyterian MediCare PPO Plan 1 (PPO) ?
Premium Breakdown
Presbyterian MediCare PPO Plan 1 (PPO) has a monthly premium of $43.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $43.00 | $0.00 | $217.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Presbyterian MediCare PPO Plan 1 (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $10,250 In and Out-of-network $6,950 In-network |
| Yes |
| In-network | No |
| In-network | $350 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | 20% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $15 copay per visit (Not applicable.) (Not applicable.) |
| out-of-network Primary | $35 copay per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $55 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $65 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $40 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $20-55 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Lab services | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $325 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $25 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $65 copay (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | $65 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $699-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $699-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | $65 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglasses (frames and lenses) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $30 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $30 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| In-network | $275 copay (Not applicable.) (Not applicable.) |
| out-of-network | $275 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $65 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 25% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 25% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
| out-of-network Diabetes supplies | 25% coinsurance per item (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | $15 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $15-35 copay (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $350 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network | $525 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $350 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $525 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $45 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $45 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $45 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $45 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | 50% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $175 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | $0 per day for days 1 through 20 $230 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
| Monthly Premium | $24.10 |
| Deductible | nan |
Optional Benefits
Package #1
| Comprehensive dental: | Monthly Premium: | $19.00 |
| Comprehensive dental: | Deductible: | N/A |
Ready to sign up for Presbyterian MediCare PPO Plan 1 (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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