Summary of Benefits. FirstMedicareDirect HMO Standard (HMO) H
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1 2017 Summary of Benefits FirstMedicareDirect HMO Standard (HMO) H This is a summary of drug and health services covered by FirstMedicare Direct HMO Standard January 1, December 31, 2017 The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage. To join FirstMedicare Direct HMO Standard you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in North Carolina: Chatham, Hoke, Lee, Montgomery, Moore, Richmond, Scotland. FirstMedicare Direct HMO Standard has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. FirstCarolinaCare Insurance Company's FirstMedicare Direct plans are HMO and PPO health plans with a Medicare contract. Enrollment in FirstMedicare Direct depends on contract renewal. H6306_17_209 Accepted 08/23/2016
2 PREMIUM and BENEFITS FirstMedicare Direct WHAT YOU SHOULD KNOW HMO Standard Monthly Plan Premium You pay $10 You must continue to pay your Medicare Part B premium. Deductible You pay nothing This plan does not have a medical deductible. Maximum Out of Pocket $3,400 annually The most you pay for copayments, coinsurance, and other costs of medical services for the year. Inpatient Hospital Care 1 Doctor Visits Primary Care Specialist SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. YOU PAY $325 Copayment per day for days 1 through 6; YOU PAY $0 for days 7 through 90 YOU PAY $35 Copayment YOU PAY $50 Copayment The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods as defined by Medicare. Preventive Care YOU PAY $0 Includes but not limited to: bone mass measurement; mammogram; cardiovascular screenings; cervical/vaginal screening; diabetes screening; PSA; vaccinations; annual wellness visit Emergency Care Copayment is waived if admitted YOU PAY $75 Copayment within 48 hours Worldwide Emergency Coverage $10,000 lifetime limit for worldwide coverage Urgently Needed Services YOU PAY $30 Copayment Diagnostic Tests, Lab, Therapeutic Radiology Services YOU PAY 20% Coinsurance Such as MRIs, CT scans, outpatient x- rays Hearing Services YOU PAY $50 Copayment Exam to diagnose and treat hearing and balance issues Dental Services YOU PAY $50 Copayment Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth) Vision Services Medicare Covered Eye Exam YOU PAY $50 Copayment Diagnose and treat diseases and conditions of the eye Medicare Covered Annual Glaucoma Test YOU PAY $0 Post Cataract Surgery Eyewear YOU PAY 20% Coinsurance Outpatient Mental Health YOU PAY $40 Copayment Group or individual therapy visits S i
3 Inpatient Mental Health Care 1 Skilled Nursing Facility (SNF) 1 Outpatient Rehabilitation Services YOU PAY $325 Copayment per day for days 1 through 6; YOU PAY $0 for days 7 through 90 YOU PAY $0 Copayment per day for days 1 through 20; YOU PAY $150 per day for days YOU PAY $40 Copayment Inpatient psychiatric care covers up to 190 days in a lifetime in a psychiatric hospital. This limit does not apply to inpatient mental services provided in a general hospital. This plan covers 100 days per cause Occupational, physical, speech and language therapies Ambulance 1 YOU PAY $300 Copayment Medically necessary ground or air medical transportation Transportation NOT COVERED Non-medical transportation is not a covered service. Foot Care (podiatry services) YOU PAY $50 Copayment Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions Durable medical equipment 1 YOU PAY 20% Coinsurance Includes wheelchairs, oxygen, etc. Fitness Center Membership YOU PAY $10 per month If member does not reside within 15 miles of a FirstHealth Health & Fitness Facility, you can be reimbursed up to $180 per yr for fees for FCC approved fitness facility. Medicare Part B Drugs YOU PAY 20% Coinsurance Cardiac Rehabilitation YOU PAY $0 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) Chiropractic Care YOU PAY $20 Copayment Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position) Diabetes Supplies and Services YOU PAY $0 if purchased at Diabetes monitoring supplies pharmacy or 20% Coinsurance if purchased from other supplier YOU PAY $0 Diabetes self-management training YOU PAY 20% Coinsurance Therapeutic shoes or inserts Home Health Care YOU PAY 15% Coinsurance Outpatient Surgery YOU PAY $300 Copayment Ambulatory or Outpatient Hospital One copayment for bilateral cataract surgery if both performed in same calendar year
4 Annual Physical Exam YOU PAY $0 Part D Deductible TIERS SUPPLEMENTAL BENEFITS YOU PAY $300 Annually Does not apply to Tier 1 drugs STANDARD RETAIL COST- STANDARD MAIL ORDER COST- SHARING SHARING One month (30 day) supply dispensed Tier 1 (Preferred Generic) YOU PAY $9 YOU PAY $3 Tier 2 (Generic) YOU PAY $20 YOU PAY $20 Tier 3 (Preferred Brand) YOU PAY $45 YOU PAY $45 Tier 4 (Non-Preferred Brand) YOU PAY $90 YOU PAY $90 Tier 5 (Specialty) YOU PAY 25% of the cost YOU PAY 25% of the cost Two month (60 day) supply dispensed Tier 1 (Preferred Generic) YOU PAY $18 YOU PAY $3 Tier 2 (Generic) YOU PAY $40 YOU PAY $40 Tier 3 (Preferred Brand) YOU PAY $90 YOU PAY $90 Tier 4 (Non-Preferred Brand) YOU PAY $180 YOU PAY $180 Tier 5 (Specialty) Not Offered Not Offered Long Term (90 day) supply dispensed Tier 1 (Preferred Generic) YOU PAY $27 YOU PAY $3 Tier 2 (Generic) YOU PAY $60 YOU PAY $50 Tier 3 (Preferred Brand) YOU PAY $135 YOU PAY $ Tier 4 (Non-Preferred Brand) YOU PAY $270 YOU PAY $225 Tier 5 (Specialty) Not Offered Not Offered Cost-sharing may change depending when you enter another phase of the Part D benefit. For more information on the phases of drug coverage, PRESCRIPTION DRUGS please call us or access our Evidence of Coverage, Chapter 6, at our website
5 For more information, if you are a member, please call Member Services toll free at (TTY users call 711). If you are not a member call us toll free at From October 1 to February 14, you can call 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern. From February 15 to September 30, you can call Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern. Or you can visit us at You can search our plan s provider and pharmacy directories on our website at We cover Part D drugs. In addition we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website at More information about your options under Medicare is available through the Medicare publication, Medicare and You. You can get it at the Medicare website ( or by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call
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