North Carolina Sandhills
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency.
Outpatient surgery: What you pay for an outpatient procedure.
Copayment/coinsurance: The set dollar amount or percentage you pay for a doctor’s visit, at the hospital or at the pharmacy. Copayment is a specific dollar amount (like $20), and coinsurance is a percentage (like 20%).
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.
Drug tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups: • Tier
1 (Preferred Generic). • Tier 2 (Generic). • Tier 3 (Preferred Brand). • Tier 4 (Non-Preferred Drug). • Tier 5 (Specialty Tier).
Generally, the higher the tier, the more you pay for the drug. Some prescriptions require step therapy (for you to try a lower tier first), prior authorization or a limit on the amount you can receive at one time. If your drug isn’t covered, you can ask for an exception. For more information, see the formulary.
Emergency care: The amount you pay for emergency care, like a trip to the emergency department. Inpatient hospital care: The amount you pay for a stay in an in-network hospital.* Lab: What you pay for lab services, like blood tests. Medical deductible: What you pay out-of-pocket before your coverage starts. Our plans don’t have medical deductibles.
North Carolina Sandhills
2021 Hometown Medicare Advantage
Key Benefits Guide
Medicare Advantage vs. Medicare Supplement Get More out of Medicare with Medicare Advantage.
Medicare Advantage
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
Medicare Supplement
Comfort of having an in-network primary care provider to oversee all your care.
Generally gives you the flexibility to see any doctor who accepts Original Medicare.
Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
Replaces Original Medicare.
Supplements Original Medicare.
Urgent care: The amount you pay for urgent or convenient care.
May cover benefits that Original Medicare doesn’t.
Only covers expenses covered by Original Medicare.
Yearly limit: The limit of how much money you pay for covered medical services, including copayments and coinsurance, each year. It’s also called out-of-pocket maximum.
No medical underwriting.
Medical underwriting.
Lower premiums than Medicare Supplement plans.
Higher premiums than Medicare Advantage plans.
Who pays in what order: Health plan, you.
Who pays in what order: Original Medicare, health plan, you.
Not age- or tobacco-rated.
Age- and tobacco-rated.
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.* Skilled nursing facility (SNF): What you pay for an approved stay at a SNF.
(except for guaranteed issue plans)
* Review the provider directory at FirstMedicare.com for our in-network doctors and hospitals. With both a POS and PPO, you have the freedom to go out of network. You save money by staying in-network.
Use the guide inside to see the amount you pay for some commonly used benefits and to learn more about some of the many perks that come with your plan. FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO health plans with Medicare contracts. Enrollment in FirstMedicare Direct depends on contract renewal. You must continue to pay your Medicare Part B premium. Out-of-network/non-contracted providers are under no obligation to treat FirstMedicare Direct members, except in emergency situations. For accommodations of persons with special needs at meetings call Member Services. Please contact our Member Services number at (877) 210-9167 TTY: 711, 8 a.m. to 8 p.m. Eastern, seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Other pharmacies/physicians/providers are available in our network. This information is not a complete description of benefits. Call (877) 210-9167 (TTY: 711) for more information.
MDMKFC21-SHLfoldguide-0420 • Y0094_21_89274_M
(888) 382-9781 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 FirstMedicare.com
North Carolina Sandhills
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency.
Outpatient surgery: What you pay for an outpatient procedure.
Copayment/coinsurance: The set dollar amount or percentage you pay for a doctor’s visit, at the hospital or at the pharmacy. Copayment is a specific dollar amount (like $20), and coinsurance is a percentage (like 20%).
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.
Drug tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups: • Tier
1 (Preferred Generic). • Tier 2 (Generic). • Tier 3 (Preferred Brand). • Tier 4 (Non-Preferred Drug). • Tier 5 (Specialty Tier).
Generally, the higher the tier, the more you pay for the drug. Some prescriptions require step therapy (for you to try a lower tier first), prior authorization or a limit on the amount you can receive at one time. If your drug isn’t covered, you can ask for an exception. For more information, see the formulary.
Emergency care: The amount you pay for emergency care, like a trip to the emergency department. Inpatient hospital care: The amount you pay for a stay in an in-network hospital.* Lab: What you pay for lab services, like blood tests. Medical deductible: What you pay out-of-pocket before your coverage starts. Our plans don’t have medical deductibles.
North Carolina Sandhills
2021 Hometown Medicare Advantage
Key Benefits Guide
Medicare Advantage vs. Medicare Supplement Get More out of Medicare with Medicare Advantage.
Medicare Advantage
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
Medicare Supplement
Comfort of having an in-network primary care provider to oversee all your care.
Generally gives you the flexibility to see any doctor who accepts Original Medicare.
Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
Replaces Original Medicare.
Supplements Original Medicare.
Urgent care: The amount you pay for urgent or convenient care.
May cover benefits that Original Medicare doesn’t.
Only covers expenses covered by Original Medicare.
Yearly limit: The limit of how much money you pay for covered medical services, including copayments and coinsurance, each year. It’s also called out-of-pocket maximum.
No medical underwriting.
Medical underwriting.
Lower premiums than Medicare Supplement plans.
Higher premiums than Medicare Advantage plans.
Who pays in what order: Health plan, you.
Who pays in what order: Original Medicare, health plan, you.
Not age- or tobacco-rated.
Age- and tobacco-rated.
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.* Skilled nursing facility (SNF): What you pay for an approved stay at a SNF.
(except for guaranteed issue plans)
* Review the provider directory at FirstMedicare.com for our in-network doctors and hospitals. With both a POS and PPO, you have the freedom to go out of network. You save money by staying in-network.
Use the guide inside to see the amount you pay for some commonly used benefits and to learn more about some of the many perks that come with your plan. FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO health plans with Medicare contracts. Enrollment in FirstMedicare Direct depends on contract renewal. You must continue to pay your Medicare Part B premium. Out-of-network/non-contracted providers are under no obligation to treat FirstMedicare Direct members, except in emergency situations. For accommodations of persons with special needs at meetings call Member Services. Please contact our Member Services number at (877) 210-9167 TTY: 711, 8 a.m. to 8 p.m. Eastern, seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Other pharmacies/physicians/providers are available in our network. This information is not a complete description of benefits. Call (877) 210-9167 (TTY: 711) for more information.
MDMKFC21-SHLfoldguide-0420 • Y0094_21_89274_M
(888) 382-9781 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 FirstMedicare.com
North Carolina Sandhills
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency.
Outpatient surgery: What you pay for an outpatient procedure.
Copayment/coinsurance: The set dollar amount or percentage you pay for a doctor’s visit, at the hospital or at the pharmacy. Copayment is a specific dollar amount (like $20), and coinsurance is a percentage (like 20%).
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.
Drug tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups: • Tier
1 (Preferred Generic). • Tier 2 (Generic). • Tier 3 (Preferred Brand). • Tier 4 (Non-Preferred Drug). • Tier 5 (Specialty Tier).
Generally, the higher the tier, the more you pay for the drug. Some prescriptions require step therapy (for you to try a lower tier first), prior authorization or a limit on the amount you can receive at one time. If your drug isn’t covered, you can ask for an exception. For more information, see the formulary.
Emergency care: The amount you pay for emergency care, like a trip to the emergency department. Inpatient hospital care: The amount you pay for a stay in an in-network hospital.* Lab: What you pay for lab services, like blood tests. Medical deductible: What you pay out-of-pocket before your coverage starts. Our plans don’t have medical deductibles.
North Carolina Sandhills
2021 Hometown Medicare Advantage
Key Benefits Guide
Medicare Advantage vs. Medicare Supplement Get More out of Medicare with Medicare Advantage.
Medicare Advantage
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
Medicare Supplement
Comfort of having an in-network primary care provider to oversee all your care.
Generally gives you the flexibility to see any doctor who accepts Original Medicare.
Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
Replaces Original Medicare.
Supplements Original Medicare.
Urgent care: The amount you pay for urgent or convenient care.
May cover benefits that Original Medicare doesn’t.
Only covers expenses covered by Original Medicare.
Yearly limit: The limit of how much money you pay for covered medical services, including copayments and coinsurance, each year. It’s also called out-of-pocket maximum.
No medical underwriting.
Medical underwriting.
Lower premiums than Medicare Supplement plans.
Higher premiums than Medicare Advantage plans.
Who pays in what order: Health plan, you.
Who pays in what order: Original Medicare, health plan, you.
Not age- or tobacco-rated.
Age- and tobacco-rated.
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.* Skilled nursing facility (SNF): What you pay for an approved stay at a SNF.
(except for guaranteed issue plans)
* Review the provider directory at FirstMedicare.com for our in-network doctors and hospitals. With both a POS and PPO, you have the freedom to go out of network. You save money by staying in-network.
Use the guide inside to see the amount you pay for some commonly used benefits and to learn more about some of the many perks that come with your plan. FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO health plans with Medicare contracts. Enrollment in FirstMedicare Direct depends on contract renewal. You must continue to pay your Medicare Part B premium. Out-of-network/non-contracted providers are under no obligation to treat FirstMedicare Direct members, except in emergency situations. For accommodations of persons with special needs at meetings call Member Services. Please contact our Member Services number at (877) 210-9167 TTY: 711, 8 a.m. to 8 p.m. Eastern, seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Other pharmacies/physicians/providers are available in our network. This information is not a complete description of benefits. Call (877) 210-9167 (TTY: 711) for more information.
MDMKFC21-SHLfoldguide-0420 • Y0094_21_89274_M
(888) 382-9781 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 FirstMedicare.com
Plan†
1
2
3
4
1
2
Plan Costs
Office Visits
Network
FirstMedicare Direct In-Network POS Plus (HMO-POS) OON FirstMedicare Direct POS Choice (HMO-POS)
In-Network
FirstMedicare Direct POS Standard (HMO-POS)
In-Network
FirstMedicare Direct PPO Plus (PPO)
In-Network
Premium
$45
$0
$73
5
FirstMedicare Direct PPO Premier (PPO)
In-Network
$154
OON
20%
20%
30%
30%
$20
20%
30%
30%
$0
$30
20%
$0
$0
$20
20%
20%
$0
$5,000
$0
$45
$0
$30
$20
20%
20%
20%
$10,000
30%
$65
$0
30%
30%
30%
30%
$5,000
$0
$30
$0
$30
$20
20%
$10,000
30%
$65
$0
30%
30%
$6,500
$5
$45
$0
$30
$10,000
30%
$65
$0
$5,500
$10
$35
$10,000
20%
$6,700 $10,000
$0
Key: This is a summary of commonly used benefits. IN means in-network, and OON means out-of-network.
*** Emergency care available worldwide. + Also called convenient or walk-in care
The OON yearly limit includes your combined costs for both in-network and out-of-network care. » Non-emergency cost-sharing may vary. Contact the plan for details.
Initial Rx Coverage
$350
Chiropractic Lab
OON
Hospital Services
30%
Physical Therapy
$0
Emergency Services
$90
Virtual Visit
OON
6
$350
Specialist Visit
$0
5
Urgent Care+
Yearly Limit PCP Visit (does not include pharmacy)
$0
4
Emergency Care***
Medical Deductible
OON $0
3 Diagnostic Services
^ You pay nothing for days 91 and beyond in-network.
X-Ray
CT/MRI
Ambulance»
Outpatient Hospital Care
Inpatient Hospital Care^ (including services received)
Skilled Nursing Facility (noncustodial care based on medical necessity)
$10
$0
$295/Day (1-6), $0/Day (7-90)
$0/Day (1-20), $184/Day (21-100)
$90
$10
30%
30%
30%
$350
$90
$10
$0
$295/Day (1-6), $0/Day (7-90)
$0/Day (1-20), $184/Day (21-100)
30%
$350
$90
$10
30%
30%
30%
20%
20%
$350
$90
$20
20%
$325/Day (1-6), $0/Day (7-90)
$0/Day (1-20), $184/Day (21-100)
30%
30%
30%
$350
$90
$20
30%
30%
30%
$20
20%
20%
20%
$350
$90
$15
$0
$310/Day (1-6), $0/Day (7-90)
$0/Day (1-20), $184/Day (21-100)
20%
20%
30%
30%
30%
$350
$90
$15
20%
20%
20%
$0
$20
$20
0%
0%
10%
$350
$90
$10
$0
$310/Day (1-6), $0/Day (7-90)
$0/Day (1-20), $184/Day (21-100)
$0
20%
20%
30%
30%
30%
$350
$90
$10
20%
20%
20%
Hometown Perks and Programs Fitness Benefit
Preventive Care
Dental Coverage
Vision Coverage
Get fit with the help of our fitness benefit. You can use any FirstHealth Center for Health & Fitness location with no benefit limit, or you can use planapproved medical fitness centers, reimbursement varies by plan.
Focus on prevention with coverage for a yearly wellness visit, routine screenings, flu shot and more.
Get covered preventive dental services, including one annual cleaning, one annual exam and one annual X-ray visit, for a $0 copay.
Get coverage for one routine eye exam up to $130.
Care Coordination and Health Coaching
We’re pleased to partner with Delta Dental to offer optional buy-up dental plans. Refer to the Delta Dental fliers in the Medicare Advantage Guide for more information.
Nurse Advice Line Get access to healthcare information from specially trained nurses, 24 hours a day, seven days a week, with the Nurse Advice Line.
Connect to a team of providers who work with your doctor to make sure you have the resources you need to stay healthy or work through your medical issues.
(for 30-day supply; applies only to Rx plans)
Rx Deductible
$0
Rx Cost by Tier 1
2
3
4
5
Rx Gap Coverage
$2
$15
$47
50%
33%
Coverage through the GAP for Tier 1
No Pharmacy Coverage
$150 (Tiers 3,4,5)
$5
$20
$47
$100
30%
Coverage through the GAP for Tier 1
$0
$2
$15
$47
50%
33%
Coverage through the GAP for Tier 1
$0
$0
$10
$47
50%
33%
Coverage through the GAP for Tier 1
North Carolina Sandhills
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency.
Outpatient surgery: What you pay for an outpatient procedure.
Copayment/coinsurance: The set dollar amount or percentage you pay for a doctor’s visit, at the hospital or at the pharmacy. Copayment is a specific dollar amount (like $20), and coinsurance is a percentage (like 20%).
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.
Drug tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups: • Tier
1 (Preferred Generic). • Tier 2 (Generic). • Tier 3 (Preferred Brand). • Tier 4 (Non-Preferred Drug). • Tier 5 (Specialty Tier).
Generally, the higher the tier, the more you pay for the drug. Some prescriptions require step therapy (for you to try a lower tier first), prior authorization or a limit on the amount you can receive at one time. If your drug isn’t covered, you can ask for an exception. For more information, see the formulary.
Emergency care: The amount you pay for emergency care, like a trip to the emergency department. Inpatient hospital care: The amount you pay for a stay in an in-network hospital.* Lab: What you pay for lab services, like blood tests. Medical deductible: What you pay out-of-pocket before your coverage starts. Our plans don’t have medical deductibles.
North Carolina Sandhills
2021 Hometown Medicare Advantage
Key Benefits Guide
Medicare Advantage vs. Medicare Supplement Get More out of Medicare with Medicare Advantage.
Medicare Advantage
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
Medicare Supplement
Comfort of having an in-network primary care provider to oversee all your care.
Generally gives you the flexibility to see any doctor who accepts Original Medicare.
Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
Replaces Original Medicare.
Supplements Original Medicare.
Urgent care: The amount you pay for urgent or convenient care.
May cover benefits that Original Medicare doesn’t.
Only covers expenses covered by Original Medicare.
Yearly limit: The limit of how much money you pay for covered medical services, including copayments and coinsurance, each year. It’s also called out-of-pocket maximum.
No medical underwriting.
Medical underwriting.
Lower premiums than Medicare Supplement plans.
Higher premiums than Medicare Advantage plans.
Who pays in what order: Health plan, you.
Who pays in what order: Original Medicare, health plan, you.
Not age- or tobacco-rated.
Age- and tobacco-rated.
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.* Skilled nursing facility (SNF): What you pay for an approved stay at a SNF.
(except for guaranteed issue plans)
* Review the provider directory at FirstMedicare.com for our in-network doctors and hospitals. With both a POS and PPO, you have the freedom to go out of network. You save money by staying in-network.
Use the guide inside to see the amount you pay for some commonly used benefits and to learn more about some of the many perks that come with your plan. FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO health plans with Medicare contracts. Enrollment in FirstMedicare Direct depends on contract renewal. You must continue to pay your Medicare Part B premium. Out-of-network/non-contracted providers are under no obligation to treat FirstMedicare Direct members, except in emergency situations. For accommodations of persons with special needs at meetings call Member Services. Please contact our Member Services number at (877) 210-9167 TTY: 711, 8 a.m. to 8 p.m. Eastern, seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Other pharmacies/physicians/providers are available in our network. This information is not a complete description of benefits. Call (877) 210-9167 (TTY: 711) for more information.
MDMKFC21-SHLfoldguide-0420 • Y0094_21_89274_M
(888) 382-9781 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 FirstMedicare.com