Drug Benefit Description

Service Area

Our 2010 approved service areas for the State of New Mexico are:

• Otero and Dona Ana Counties

Benefits

Applicable conditions and limitations include:

• Must reside in an approved Physicians Health Choice service area.
• Applicants must be eligible for Medicare Part A and B.
• Where applicable, applicants must be eligible for both Medicare A and B as well as Medicaid benefits.

To find out information regarding co-payments and coinsurance regarding drug costs, select a health plan in your County below:

• Las Cruces & Alamogordo Areas
  Dona Ana / Otero Counties
  Standard and Extra HMO Plans - PDF
  Select HMO Plan - PDF

Members will receive a notice within 60 days regarding removal or change in the preferred or tiered cost-sharing status of a Part D Drug.

Pharmacy Access Information

• Pharmacy addresses and type of pharmacy (e.g. retail, mail-order, home infusion) can be found in the Pharmacy Directory.
• Network pharmacy information can be found in the Pharmacy Directory.
• Physicians Health Choice has contracts with pharmacies which equals or exceeds CMS requirements for pharmacy access in your area.

Out-of-Network Coverage

Covered Part D drugs are available at out-of-network pharmacies in special circumstances, including member’s illness while traveling outside of the Plan’s service area and where there is no network pharmacy.

Prescription Formulary

The Prescription Formulary information is updated on a monthly basis.

Part D Grievance and Appeals Process

To learn more about the processes regarding grievances, coverage determinations, appeals procedures and exceptions please refer to the 2010 Evidence of Coverage.

Quality Assurance Policies & Procedures

Physicians Health Choice has established a Quality Assurance / Improvement Program whose purpose is to ensure that the quality, safety and appropriateness of member care and service delivered, meets or exceeds established plan, state and federal managed care standards (including medication therapy management, and drug and/or utilization management).

The Quality Improvement Department works together with all Physicians Health Choice departments to ensure the systems, operations and requirements of the Quality Improvement Program are met and provide the highest quality of care and service to our members and providers.

Physicians Health Choice’s goal is to support good health by providing quality care and customer service through teamwork, using responsible and innovative management and emphasizing healthy lifestyles with improved outcomes.

This goal is accomplished through focusing on continuous quality improvement and leveraging best practices in the healthcare delivery system.

If you have any questions about this program or any concerns about the quality of care and service you have received please call toll free the Member Service Department at 1-866-550-4736.

Physicians Health Choice Contract Terminatio

For information regarding what will happen if Physicians Health Choice should leave the Medicare program or the service area you live in, please refer to 2010 Evidence of Coverage.

Member Rights & Responsibilities Upon Disenrollment

To learn more about a member’s rights and responsibilities upon disenrollment please refer to 2010 Evidence of Coverage.

Part D Grievance and Appeals Process

As a member of Physicians Health Choice, you are entitled to obtain an aggregate number of our grievances, appeals and exceptions. You may do this by sending a written request to our office address:

Physicians Health Choice
Attn: Customer Service
P.O. Box 690670
San Antonio, TX 78269

Fraud, Waste and Abuse

Physicians Health Choice is committed to protecting your Medicare tax dollars. Our Fraud, Waste and Abuse Hotline is available to anyone with concerns about potential fraud or abuse of their prescription drug benefits. If you wish, your call will be kept confidential to the fullest extent allowable by law. The Fraud, Waste and Abuse hotline is toll-free at 1-800-830-0817 (TTY/TDD users may call 711).