FirstMedicare Direct Healthy State HMO Prime (HMO) 2018 Summary of Benefits
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1 Healthy State HMO Prime (HMO) 2018 Summary of Benefits This is a summary of drug and health services covered January 1, 2018-December 31, 2018 by the FirstMedicare Direct. The benefit information provided is a summary of what we cover and what you pay. It does not list every service that is covered or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage. To join 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: Buncombe, Henderson, Madison, McDowell, Transylvania and Yancey. 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. H6306_18_702 Accepted 8/29/2017
2 Monthly Plan Premium YOU PAY $17 You must continue to pay your Medicare Part B premium. Part C Deductible YOU PAY nothing This plan does not have a deductible. Maximum Out of Pocket Inpatient Hospital Care* Outpatient Hospital Services $6,700 annually SERVICES WITH A * MAY REQUIRE PRIOR AUTHORIZATION Doctor Visits Primary Care Providers Specialists Preventive Care YOU PAY $0 Emergency Care Urgently Needed Services Diagnostic Tests, Lab, Therapeutic Radiology Services and X-rays* Hearing Services Dental Services Vision Services Medicare Covered Eye Exam Medicare Covered Annual Glaucoma Test YOU PAY $350 Copayment per day for days 1 through 4; YOU PAY $0 for days 5 through 90 YOU PAY $300 Copayment YOU PAY $10 Copayment YOU PAY $80 Copayment YOU PAY $30 Copayment YOU PAY $0 The most you pay for copayments, coinsurance, and other costs of medical services for the year. The copayments for hospital and skilled nursing facility (SNF) benefits are based on Medicare defined benefit periods. Includes outpatient hospital or ambulatory surgery services. One copayment for bilateral cataract surgery if both performed in same calendar year. Includes but is not limited to: bone mass measurement; mammogram; cardiovascular screenings; cervical/vaginal screening; diabetes screening; PSA; vaccinations; annual wellness visit. Copayment is waived if admitted within 48 hours. $10,000 lifetime limit for worldwide emergency coverage outside of the United States. Such as MRIs, CT scans, outpatient X- rays. Authorization required for genetic testing. Exam to diagnose and treat hearing and balance issues. Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth). Diagnose and treat diseases and conditions of the eye.
3 Post Cataract Surgery Eyewear Outpatient Mental Health Services YOU PAY $40 Copayment Group or individual therapy visit. Inpatient Mental Health Care* Skilled Nursing Facility (SNF)* Outpatient Rehabilitation Services Ambulance* Transportation (non-medical) Medicare Part B Drugs* Foot Care (podiatry services) YOU PAY $350 Copayment per day for days 1 through 4; YOU PAY $0 for days 5 through 90 YOU PAY $0 Copayment per day for days 1 through 20; YOU PAY $160 per day for days 21 through 100 YOU PAY $30 Copayment YOU PAY $350 Copayment NOT COVERED 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. Medically necessary ground or air medical transportation. Authorization required for nonemergency services. Non-medical transportation is not a covered service. Only certain medications require authorization. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions. Durable Medical Equipment* Includes wheelchairs, oxygen, etc. Cardiac Rehabilitation YOU PAY $0 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 Dialysis Home Health Care YOU PAY 0% - 20% Coinsurance YOU PAY 0% Coinsurance Prosthetic devices (braces, artificial limbs, etc.)* SUPPLEMENTAL BENEFITS Includes related medical supplies. Routine Eye Exam YOU PAY $25 Copayment $100 annual limit.
4 Annual Physical Exam YOU PAY $0 Fitness Benefit YOU PAY $0 Members must use YMCA of Western NC facilities. May be reimbursed a maximum of $510 annually. Payment receipts required. PRESCRIPTION DRUGS Part D Deductible YOU PAY $200 annually TIERS RETAIL COST MAIL ORDER COST One month (30 day) supply dispensed Tier 1 (Preferred Generic Drugs) YOU PAY $6 YOU PAY $6 Tier 2 (Generic Drugs) YOU PAY $20 YOU PAY $20 Tier 3 (Preferred Brand Drugs) YOU PAY $45 YOU PAY $45 Tier 4 (Non-Preferred Drugs) YOU PAY $90 YOU PAY $90 Tier 5 (Specialty Drugs) YOU PAY 29% of the cost YOU PAY 29% of the cost Tier 6 (Select Care Drugs) YOU PAY $6 YOU PAY $6 Two month (60 day) supply dispensed Tier 1 (Preferred Generic Drugs) YOU PAY $12 YOU PAY $0 Tier 2 (Generic Drugs) YOU PAY $40 YOU PAY $40 Tier 3 (Preferred Brand Drugs) YOU PAY $90 YOU PAY $90 Tier 4 (Non-Preferred Drugs) YOU PAY $180 YOU PAY $180 Tier 5 (Specialty Drugs) Not Offered Not Offered Tier 6 (Select Care Drugs) YOU PAY $6 YOU PAY $6 Long term (90 day) supply dispensed Tier 1 (Preferred Generic Drugs) YOU PAY $18 YOU PAY $0 Tier 2 (Generic Drugs) YOU PAY $60 YOU PAY $50 Tier 3 (Preferred Brand Drugs) YOU PAY $135 YOU PAY $ Tier 4 (Non-Preferred Drugs) YOU PAY $270 YOU PAY $225 Tier 5 (Specialty Drugs) Not Offered Not Offered Tier 6 (Select Care Drugs) YOU PAY $0 YOU PAY $0 Cost-sharing may change depending when you enter another phase of the Part D benefit. For more information on the phases of drug coverage, 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 http :// or by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call
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