Western North Carolina
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.
Western North Carolina
2022 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 a POS plan, 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 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 (800) 481-0496 (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 (800) 984-3510 (TTY 711) for more information.
MDMKFC22-WNCfoldguide-0621 • H6306_22_99225_M
(800) 481-0496 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 FirstMedicare.com
Western North Carolina
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.
Western North Carolina
2022 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 a POS plan, 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 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 (800) 481-0496 (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 (800) 984-3510 (TTY 711) for more information.
MDMKFC22-WNCfoldguide-0621 • H6306_22_99225_M
(800) 481-0496 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 FirstMedicare.com
Western North Carolina
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.
Western North Carolina
2022 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 a POS plan, 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 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 (800) 481-0496 (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 (800) 984-3510 (TTY 711) for more information.
MDMKFC22-WNCfoldguide-0621 • H6306_22_99225_M
(800) 481-0496 (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
1
2
Plan Costs
Office Visits
Network
FirstMedicare Direct POS Standard (HMO-POS)
IN
Premium Medical Deductible
Yearly Limit PCP Visit (does not include pharmacy)
Specialist Visit
Virtual Visit
Physical Therapy
Chiropractic Lab
$0
$6,700
$45
$0
$30
$20
$0
OON
2
FirstMedicare Direct POS Plus (HMO-POS)
IN OON
$39
$0
$10
$0
X-Ray
$0
CT/MRI
20%
4
5
6
Emergency Services
Hospital Services
Initial Rx Coverage
Ambulance»
$350
Emergency Care***
Urgent Care+
$90
$40
Outpatient Hospital Care
Inpatient Hospital Care^ (including services received)
Skilled Nursing Facility (noncustodial care based on medical necessity)
$300
$450/Day (1-4), $0/Day (5-90)
$0/Day (1-20), $188/Day (21-100)
$10,000
30%
$65
$0
30%
30%
30%
30%
30%
$350
$90
$40
30%
30%
30%
$3,450
$5
$45
$0
$30
$20
$0
$0
20%
$250
$120
$30
$250
$325/Day (1-4), $0/Day (5-90)
$0/Day (1-20), $188/Day (21-100)
$10,000
Key: This is a summary of commonly used benefits. IN means in-network, and OON means out-of-network.
3 Diagnostic Services
30%
$65
$0
30%
30%
30%
30%
30%
$250
$120
$30
30%
30%
Perks and Programs
*** Emergency care available worldwide.
Fitness Benefit
Dental Coverage
Virtual Visits
+ Also called convenient or walk-in care.
Get fit with the help of our fitness benefit. You can use any Western North Carolina YMCA facility for a $0 copay per month.
Get covered preventive dental services, including two cleanings per year, two oral exams and one annual X-ray visit, for a $0 copay.
Talk to a board certified doctor by phone or secure video 24/7 with FirstHealth on the Go.
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.
Get one routine hearing exam for a $45 copay when you see a TruHearing® provider and lowered rates on up to two TruHearing hearing aids per year.
The OON yearly limit includes your combined costs for both in-network and out-of-network care.
^ You pay nothing for days 91 and beyond in-network.
Care Coordination
» Non-emergency cost-sharing may vary. Contact the plan for details.
† Members on POS plans may pay more for preventive care out of network.
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 and a $130 allowance for eyewear.
Hearing Benefit
30%
(for 30-day supply)
Rx Deductible
Rx Cost by Tier 1
2
3
4
5
Rx Gap 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
Western North Carolina
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.
Western North Carolina
2022 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 a POS plan, 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 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 (800) 481-0496 (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 (800) 984-3510 (TTY 711) for more information.
MDMKFC22-WNCfoldguide-0621 • H6306_22_99225_M
(800) 481-0496 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 FirstMedicare.com