North Carolina Triangle
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency. 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%). 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.
North Carolina Triangle
2022 Medicare Advantage Key Benefits Guide
Medical deductible: What you pay out-of-pocket before your coverage starts. Our plans don’t have medical deductibles. Outpatient surgery: What you pay for an outpatient procedure.
Medicare Advantage vs. Medicare Supplement Get More out of Medicare with Medicare Advantage.
Medicare Advantage
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare. Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium. 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. Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
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.
Replaces Original Medicare.
Supplements Original Medicare.
May cover benefits that Original Medicare doesn’t.
Only covers expenses covered by Original Medicare.
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.
Urgent care: The amount you pay for urgent or convenient care.
Inpatient hospital care: The amount you pay for a stay in an in-network hospital.*
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.
Lab: What you pay for lab services, like blood tests.
* R eview the provider directory at FirstMedicare.com for our in-network doctors and hospitals.
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 is a health plan with a Medicare contract. Enrollment in FirstCarolinaCare 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 FirstCarolinaCare members, except in emergency situations. For accommodations of persons with special needs at meetings, call (877) 749-3356 (TTY 711), 8 a.m. to 8 p.m. local time. Voicemail used on holidays and weekends, April 1 through September 30. Other pharmacies/physicians/providers are available in our network. This information is not a complete description of benefits. Call (844) 499-5630 (TTY 711) for more information.
MDMKFC22-TRGfoldguide-0621 • H6306_22_99307_M
(877) 749-3356 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 FirstMedicare.com
Medicare Supplement
(except for guaranteed issue plans)
North Carolina Triangle
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency. 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%). 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.
North Carolina Triangle
2022 Medicare Advantage Key Benefits Guide
Medical deductible: What you pay out-of-pocket before your coverage starts. Our plans don’t have medical deductibles. Outpatient surgery: What you pay for an outpatient procedure.
Medicare Advantage vs. Medicare Supplement Get More out of Medicare with Medicare Advantage.
Medicare Advantage
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare. Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium. 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. Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
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.
Replaces Original Medicare.
Supplements Original Medicare.
May cover benefits that Original Medicare doesn’t.
Only covers expenses covered by Original Medicare.
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.
Urgent care: The amount you pay for urgent or convenient care.
Inpatient hospital care: The amount you pay for a stay in an in-network hospital.*
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.
Lab: What you pay for lab services, like blood tests.
* R eview the provider directory at FirstMedicare.com for our in-network doctors and hospitals.
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 is a health plan with a Medicare contract. Enrollment in FirstCarolinaCare 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 FirstCarolinaCare members, except in emergency situations. For accommodations of persons with special needs at meetings, call (877) 749-3356 (TTY 711), 8 a.m. to 8 p.m. local time. Voicemail used on holidays and weekends, April 1 through September 30. Other pharmacies/physicians/providers are available in our network. This information is not a complete description of benefits. Call (844) 499-5630 (TTY 711) for more information.
MDMKFC22-TRGfoldguide-0621 • H6306_22_99307_M
(877) 749-3356 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 FirstMedicare.com
Medicare Supplement
(except for guaranteed issue plans)
North Carolina Triangle
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency. 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%). 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.
North Carolina Triangle
2022 Medicare Advantage Key Benefits Guide
Medical deductible: What you pay out-of-pocket before your coverage starts. Our plans don’t have medical deductibles. Outpatient surgery: What you pay for an outpatient procedure.
Medicare Advantage vs. Medicare Supplement Get More out of Medicare with Medicare Advantage.
Medicare Advantage
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare. Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium. 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. Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
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.
Replaces Original Medicare.
Supplements Original Medicare.
May cover benefits that Original Medicare doesn’t.
Only covers expenses covered by Original Medicare.
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.
Urgent care: The amount you pay for urgent or convenient care.
Inpatient hospital care: The amount you pay for a stay in an in-network hospital.*
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.
Lab: What you pay for lab services, like blood tests.
* R eview the provider directory at FirstMedicare.com for our in-network doctors and hospitals.
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 is a health plan with a Medicare contract. Enrollment in FirstCarolinaCare 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 FirstCarolinaCare members, except in emergency situations. For accommodations of persons with special needs at meetings, call (877) 749-3356 (TTY 711), 8 a.m. to 8 p.m. local time. Voicemail used on holidays and weekends, April 1 through September 30. Other pharmacies/physicians/providers are available in our network. This information is not a complete description of benefits. Call (844) 499-5630 (TTY 711) for more information.
MDMKFC22-TRGfoldguide-0621 • H6306_22_99307_M
(877) 749-3356 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 FirstMedicare.com
Medicare Supplement
(except for guaranteed issue plans)
Plan
1
1
2
Plan Costs
Office Visits
Network
FirstMedicare Direct SmartHMO (HMO)
IN
Premium Medical Deductible
Yearly Limit (does not include pharmacy)
PCP Visit
$0
$2,900
$0
$0
3 Diagnostic Services
Specialist Visit
Physical Therapy
Chiropractic
$35
$10-$40
$10
Lab
$0-$95
X-Ray
$0-$95
CT/MRI
$40-$295
4
5
6
Emergency Services
Hospital Services
Initial Rx Coverage
Ambulance»
$100
Emergency Care***
Urgent Care+
$80
$0
Outpatient Hospital Care
Inpatient Hospital Care^ (including services received)
Skilled Nursing Facility (noncustodial care based on medical necessity)
$150
$150/Day (1-5), $0/Day (6-90)
$0/Day (1-20), $100/Day (21-100)
(for 30-day supply)
Rx Deductible
$0
Key: This is a summary of commonly used benefits. IN means in network. » Non-emergency cost-sharing may vary. Contact the plan for details.
*** Emergency care available worldwide. + Also called convenient or walk-in care. ^ You pay nothing for days 91 and beyond in-network.
Perks and Programs Fitness Benefit
Dental Coverage
OTC Benefit
Get fit with the help of our fitness benefit for no cost. Get access to a variety of fitness options and community events. Keep your routine or add to it. You decide how to stay active and healthy.
Get covered preventive dental services, including one cleaning and fluoride treatment every six months, and one full set of X-rays every three years.
Our plan covers a quarterly over-the-counter (OTC) benefit with an annual maximum plan benefit of $75 a quarter, which allows you to purchase OTC products from a catalog with hundreds of products to choose from.
Care Coordination Connect to a team of providers who work with your doctor to make sure you have the resources you need.
Vision Coverage Get coverage for one routine eye exam yearly (copayment applies; see the Summary of Benefits for specific copayment amounts) and a $75 allowance for eyewear every two years.
Rx Cost by Tier 1
2
3
4
5
Rx Gap Coverage
$0
$10
$47
$100
33%
Coverage through the gap for Tier 1
North Carolina Triangle
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency. 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%). 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.
North Carolina Triangle
2022 Medicare Advantage Key Benefits Guide
Medical deductible: What you pay out-of-pocket before your coverage starts. Our plans don’t have medical deductibles. Outpatient surgery: What you pay for an outpatient procedure.
Medicare Advantage vs. Medicare Supplement Get More out of Medicare with Medicare Advantage.
Medicare Advantage
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare. Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium. 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. Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
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.
Replaces Original Medicare.
Supplements Original Medicare.
May cover benefits that Original Medicare doesn’t.
Only covers expenses covered by Original Medicare.
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.
Urgent care: The amount you pay for urgent or convenient care.
Inpatient hospital care: The amount you pay for a stay in an in-network hospital.*
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.
Lab: What you pay for lab services, like blood tests.
* R eview the provider directory at FirstMedicare.com for our in-network doctors and hospitals.
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 is a health plan with a Medicare contract. Enrollment in FirstCarolinaCare 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 FirstCarolinaCare members, except in emergency situations. For accommodations of persons with special needs at meetings, call (877) 749-3356 (TTY 711), 8 a.m. to 8 p.m. local time. Voicemail used on holidays and weekends, April 1 through September 30. Other pharmacies/physicians/providers are available in our network. This information is not a complete description of benefits. Call (844) 499-5630 (TTY 711) for more information.
MDMKFC22-TRGfoldguide-0621 • H6306_22_99307_M
(877) 749-3356 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 FirstMedicare.com
Medicare Supplement
(except for guaranteed issue plans)