Presbyterian Senior Care Plan 3 with Rx (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Presbyterian Senior Care Plan 3 with Rx (HMO) by Presbyterian Health Plan. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a New Mexico Medicare Part-C plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This Presbyterian Senior Care Plan 3 with Rx (HMO)(H3204-007) plan has a $0 drug deductible. The Initial Coverage Limit (ICL) for this plan is $4660. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Presbyterian Health Plan will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link above the chart.



Plan Overview

Plan Name:Presbyterian Senior Care Plan 3 with Rx
Plan ID: H3204-007
Provider: Presbyterian Health Plan
Plan Year:2023
Premium:$76.10
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:New Mexico
Similar Plan:H3204-013


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
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Drug
Name⇅
Tier
Level
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Paliperidone
4NA$95$951/1NY
Pancreaze
5NA33%33%NN
Panretin
5NA33%33%NN
Paricalcitol
4NA$95$95NN
Paromomycin Sulfate
2NA$10$10NN
Paroxetine
3NA$45$45YN
Paroxetine Hydrochloride
2NA$10$10YN
Paser
4NA$95$95NN
Paxil
3NA$45$45YN
Pediarix
3NA$45$45NN
Pedvaxhib
3NA$45$45NN
Peg-3350 And Electrolytes
2NA$10$10NN
Pegasys
5NA33%33%NN
Pemazyre
5NA33%33%14/21YN
Penicillamine
5NA33%33%YN
Penicillin V Potassium
2NA$10$10NN
Pentacel
3NA$45$45NN
Pentamidine Isethionate
4NA$95$95YN
Pentasa
5NA33%33%8/1NN
Pentoxifylline
2NA$10$10NN
Periogard Alcohol Free
3NA$45$45NN
Permethrin
2NA$10$10NN
Perphenazine
3NA$45$45NN
Perseris
5NA33%33%YN
Phenelzine Sulfate
2NA$10$10NN
Phenobarbital
2NA$10$10NN
Phenytoin
2NA$10$10NN
Phospholine Iodide
3NA$45$45NN
Pifeltro
5NA33%33%1/1NN
Pilocarpine Hydrochloride
2NA$10$10NN
Pimozide
2NA$10$10NN
Pindolol
2NA$10$10NN
Pioglitazone And Glimepiride
4NA$95$951/1NN
Piperacillin And Tazobactam
4NA$95$95NN
Piqray
5NA33%33%2/1YN
Pirmella 1/35
3NA$45$45NN
Piroxicam
2NA$10$10NN
Plenamine
3NA$45$45YN
Podofilox
2NA$10$10NN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
2NA$10$10NN
Polymyxin B Sulfate And Trimethoprim
2NA$10$10NN
Portia
3NA$45$45NN
Potassium Chloride
2NA$10$10NN
Potassium Citrate
2NA$10$10NN
Pradaxa
4NA$95$952/1NN
Prasugrel
4NA$95$951/1NN
Pravastatin Sodium
1NA$0$0NN
Praziquantel
3NA$45$45NN
Prazosin Hydrochloride
1NA$0$0NN
Prednisolone Acetate
3NA$45$45NN
Prednisolone Sodium Phosphate
3NA$45$45NN
Prednisone
2NA$10$10NN
Prednisone Intensol
3NA$45$45NN
Prefest
4NA$95$95YN
Pregabalin
2NA$10$10NN
Premarin
3NA$45$45YN
Premphase
3NA$45$45YN
Prempro
3NA$45$45YN
Prevymis
5NA33%33%1/1NY
Prezcobix
5NA33%33%2/1NN
Prezista
5NA33%33%1/1NN
Priftin
3NA$45$45NN
Primaquine Phosphate
3NA$45$45NN
Primidone
2NA$10$10NN
Proair Respiclick
4NA$95$95NN
Probenecid
2NA$10$10NN
Probenecid And Colchicine
2NA$10$10NN
Prochlorperazine Maleate
2NA$10$10NN
Procto-med Hc
2NA$10$10NN
Proctosol-hc
3NA$45$45NN
Proctozone-hc
3NA$45$45NN
Progesterone
2NA$10$10NN
Prograf
4NA$95$95YN
Prolastin-c
5NA33%33%YN
Prolia
4NA$95$951/180YN
Promacta
5NA33%33%6/1YN
Promethazine Hydrochloride
2NA$10$10NN
Propafenone Hydrochloride
2NA$10$10NN
Propranolol Hydrochloride
2NA$10$10NN
Propylthiouracil
2NA$10$10NN
Proquad
3NA$45$45NN
Protriptyline Hydrochloride
2NA$10$10YN
Prudoxin
4NA$95$95NN
Pulmicort
4NA$95$95NN
Pulmozyme
5NA33%33%YN
Purixan
5NA33%33%YN
Pyrazinamide
2NA$10$10NN
Pyridostigmine Bromide
5NA33%33%NN
Pyrimethamine
5NA33%33%YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3204-007

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $0. Some plans offer select Pre-deductible drug Coverage
2. Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2023 is $505. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Preferred: Your Cost for the Drug at the Providers In-Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non-Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plan's formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Last updated on

Source:CMS Formulary Data Q4 2022
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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