Presbyterian Senior Care Plan 1 (HMO)
H3204 - 008 - 0
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Presbyterian Senior Care Plan 1 (HMO) is a Medicare Advantage (Part C) Plan by Presbyterian Health Plan.
This page features plan details for 2024 Presbyterian Senior Care Plan 1 (HMO) H3204 – 008 – 0 available in Greater Albuquerque Area, Rio Arriba and Santa Fe.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Presbyterian Senior Care Plan 1 (HMO) is offered in the following locations.
Plan Overview
Presbyterian Senior Care Plan 1 (HMO) offers the following coverage and cost-sharing.
| Insurer: | Presbyterian Health Plan |
| Health Plan Deductible: | $0.00 |
| MOOP: | $4,250 In-network |
| Drugs Covered: | No |
Ready to sign up for Presbyterian Senior Care Plan 1 (HMO) ?
Premium Breakdown
Presbyterian Senior Care Plan 1 (HMO) has a monthly premium of $0.00. 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 | $0.00 | $0.00 | $174.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Presbyterian Senior Care Plan 1 (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $4,250 In-network |
| Yes |
| In-network | No |
| $350 copay per visit (Authorization is required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $55 copay per visit (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $120 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $20-60 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0 copay (Authorization is not required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is not required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $325 copay (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $25 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $699-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| 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.) |
| Routine eye exam | $0 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 | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Occupational therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| $275 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $0 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | $15 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| $350 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| 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.) |
| Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $175 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
| Monthly Premium | $25.20 |
| Deductible | nan |
Optional Benefits
Package #1
| Comprehensive dental: | Monthly Premium: | $9.00 |
| Comprehensive dental: | Deductible: | N/A |
Ready to sign up for Presbyterian Senior Care Plan 1 (HMO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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