SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION
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2 Monthly Plan Premium YOU PAY $0 You must continue to pay your Medicare Part C Deductible YOU PAY nothing This plan does not have a medical Maximum Out of Pocket $6,000 annually The most you pay for Copayments, coinsurance, and other costs of medical services for the year. SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION Inpatient Hospital Care 1 YOU PAY $300 copayment per day for days 1-6 YOU PAY $0 copayment per day for days 7-90 The Copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods as defined by Medicare. Outpatient Hospital Care Outpatient Surgery or Ambulatory Surgery Services Other Outpatient Services Observation Services Doctor Visits Primary Care Physician YOU PAY $300 copayment per visit YOU PAY $30 copayment per visit One copayment applies for bilateral cataract surgery if both performed in the same calendar year. Specialist Preventive Care Services Annual Physical Exam YOU PAY $50 copayment per visit YOU PAY $0 copayment per service YOU PAY $0 copayment per one annual visit Includes but not limited to Medicarecovered: glaucoma screening, diabetes self- management training, barium enemas, digital rectal exams, and EKG following Welcome Visit. Emergency Care YOU PAY $90 copayment per visit Copayment waived if admitted within 48 hours. Worldwide Emergency Coverage YOU PAY $90 copayment per visit Copayment is NOT waived if you are admitted to the hospital. YOU PAY $400 copayment per one- way transportation (ground or air) $10,000 lifetime limit for worldwide emergency coverage outside of the United States. Urgently Needed Services YOU PAY $30 copayment per visit Copayment is NOT waived if you are admitted to the hospital. Diagnostic Tests, Lab, Therapeutic Radiology Services and X-rays 1 Such as MRIs, CT scans, outpatient x-rays. Hearing Services YOU PAY $50 copayment per visit Medicare Covered exams to diagnose and treat hearing and balance issues.
3 Dental Services YOU PAY $50 copayment per visit Medicare Covered dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth). Vision Services Medicare Covered Eye Exam Medicare Covered Annual Glaucoma Test Post Cataract Surgery Eyewear Routine Eye Exam YOU PAY $50 copayment per visit YOU PAY $0 copayment per visit YOU PAY $50 per visit Diagnose and treat diseases and conditions of the eye. One pair of eyeglasses or contact lenses after cataract surgery. Routine Eye Exam annual $130 limit. Outpatient Mental Health Services YOU PAY $40 copayment per visit Group or individual therapy visits. Inpatient Mental Health Care 1 YOU PAY $160 copayment per day for days 1-10 Inpatient psychiatric care covers up to 190 days in a lifetime in a psychiatric hospital. Skilled Nursing Facility (SNF) 1 YOU PAY $0 copayment per day for days YOU PAY $0 copayment per day for days 1-20 This limit does not apply to inpatient mental services provided in a general hospital. This plan covers 100 days per cause. YOU PAY $170 copayment per day for days Outpatient Rehabilitation Services YOU PAY $40 copayment per visit Occupational, physical, speech and language therapies. Ambulance 1 Ground Transportation Service Air Transportation Service YOU PAY $300 copayment per one-way transportation YOU PAY $400 copayment per one-way transportation Cost sharing applies to each oneway trip. Authorization required for nonemergency services. Medically necessary Medicare- covered ground or air medical transportation. Transportation (non-medical) NOT COVERED Non-medical transportation is not a covered service. Medicare Part B Drugs 1
4 Foot Care (podiatry services) YOU PAY $50 copayment per visit Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions. Durable Medical Equipment 1 Includes wheelchairs, oxygen, etc. Cardiac Rehabilitation YOU PAY $0 copayment per visit Cardiac and Pulmonary rehabilitation visits. Chiropractic Care YOU PAY $20 copayment per visit Medicare-covered services only. Diabetes Supplies and Services Diabetes monitoring supplies from Retail Pharmacy Diabetes monitoring supplies from DME supplier Diabetes self-management training YOU PAY 0% of the total cost YOU PAY 0% of the total cost Therapeutic shoes or inserts Dialysis Home Health Care YOU PAY $0 copayment per visit Prosthetic devices 1 Braces, artificial limbs, etc. Fitness Center Membership YOU PAY $10 copayment per month Applies to fitness membership at any FirstHealth Center for Health and Fitness. A member may use another plan approved fitness center and be reimbursed up to $180 annually for fees. Reimbursements are made on a quarterly basis and will not be paid in advance.
5 PRESCRIPTION DRUGS Part D Deductible YOU PAY $300 annually Tier 1 and Tier 6 do not apply to the deductible. TIERS RETAIL COST MAIL ORDER COST One month (30 day) supply dispensed Tier 1 (Preferred Generic Drugs) YOU PAY $10 copayment YOU PAY $10 copayment Tier 2 (Generic Drugs) YOU PAY $20 copayment YOU PAY $20 copayment Tier 3 (Preferred Brand Drugs) YOU PAY $45 copayment YOU PAY $45 copayment Tier 4 (Non-Preferred Drugs) YOU PAY $100 copayment YOU PAY $100 copayment Tier 5 (Specialty Drugs) YOU PAY 25% of the total cost YOU PAY 25% of the total cost Tier 6 (Select Care Drugs) YOU PAY $10 copayment YOU PAY $10 copayment Long Term (90 day) supply dispensed Tier 1 (Preferred Generic Drugs) YOU PAY $30 copayment YOU PAY $0 copayment Tier 2 (Generic Drugs) YOU PAY $60 copayment YOU PAY $50 copayment Tier 3 (Preferred Brand Drugs) YOU PAY $135 copayment YOU PAY $ copayment Tier 4 (Non-Preferred Drugs) YOU PAY $300 copayment YOU PAY $250 copayment Tier 5 (Specialty Drugs) A long term supply is not available A long term supply is not available in Tier 5. in Tier 5. Tier 6 (Select Care Drugs) YOU PAY $0 copayment YOU PAY $0 copayment 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
6 To locate our Evidence of Coverage, visit our website at: choose Your County (e.g. Buncombe, Moore, Wake, etc.); select the Members tab; choose Coverage Documents and click on the 2019 Evidence of Coverage for your plan. This information is not a complete description of benefits. 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 March 31, you can call 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern. From April 1 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
7 Pre-Enrollment Checklist Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at Understanding the Benefits Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely see a doctor. Visit or call to view a copy of the EOC. Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor. Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions. Understanding Important Rules In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month. Benefits, premiums and/or copayments/co-insurance may change on January 1, HMO Applicants: Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory). PPO Applicants: Our plan allows you to see providers outside of our network (noncontracted providers). However, while we will pay for covered services provided by a non-contracted provider, the provider must agree to treat you. Except in an emergency or urgent situations, non-contracted providers may deny care. In addition, you will pay a higher co-pay for services received by non-contracted providers. I have read the above checklist and wish to proceed FirstCarolinaCare Insurance Company's plans are HMO and PPO plans with a Medicare contract. Enrollment in a plan depends on contract renewal. Y0094_19050_C_FMDApproved_08/13/2018
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