2024 Sandhills Medicare Advantage Guide

How to Enroll

Broker

If you attend a seminar, the person presenting can schedule an appointment to help you enroll.

After You Enroll

Fill out and mail us the enrollment form in the back of this guide. You can also download it from FirstMedicare.com.

If you enroll in a Medicare Advantage plan during the Annual Enrollment Period, your coverage will begin January 1, 2024. In the meantime, we’ll mail you your member materials and your member ID card, which you’ll use instead of your red, white and blue Medicare card at the doctor, hospital and pharmacy starting January 1.

Contents

Welcome to Hometown Medicare

Hometown Pharmacy Benefits

Stages of Pharmacy Coverage

Hometown People Focused on You

Hometown Coverage Away from Home

Perks and Programs

Your Health at Your Fingertips

Appeals and Grievances

Enrollment Timelines, Requirements

Enrollment Process

Hometown Plans

HMO-POS Plans

PPO Plans

Welcome to hometown Medicare coverage.

We’re a local health plan that gives you hometown coverage. We’ve been part of the Sandhills region since 1999, working with the doctors you know and trust, and creating plan options to fit the needs of you and our entire community. When you choose a FirstMedicare Direct plan, you know you have someone close by looking out for you through every step of the healthcare process. Use this guide to learn more. Plus, compare plan options and key benefits all in one place with the 2024 Key Medicare Advantage Benefits guide.

Hometown Pharmacy Benefits

Plans with pharmacy coverage help you keep all your coverage in one place and help you save with special programs and discounts.

Pharmacy Basics

Drug Formulary

A formulary is the list of drugs we cover. You can find it at FirstMedicare.com. (Generally, we only cover drugs that are listed.)

Pharmacy Network

You must use an in-network pharmacy to get covered drugs unless it’s an emergency. For a list of in-network pharmacies, view our pharmacy directory at FirstMedicare.com.

Savings for Members Without Part D

Our Medicare Advantage members without Part D coverage get help paying for their prescription drug costs by showing their health plan ID card.

Medication Disposal Program

You have access to Deterra®, a safe and convenient way to get rid of unwanted medication. You must call OptumRx ® at (800) 562-6223 and register a home delivery account (but you don’t have to agree to home delivery). Tell the OptumRx customer service rep you need a kit to dispose of unneeded meds. The kit should arrive in seven to 10 business days.

Drug Compare Tool

See how much you’ll pay each month and how much you could save by switching to a pharmacy with lower prescription costs or by taking a lower-cost drug.

You can check costs at different pharmacies and see the differences in costs between retail (pickup) or mail order (delivery of a 90-day supply). You can also estimate your total annual drug costs.

90-Day Supply Options

Late Enrollment Penalty

If you don’t enroll in a prescription drug (Part D) plan when you’re first eligible, you may have to pay a penalty for enrolling later. That penalty will increase for every month you didn’t have prescription coverage.

You can’t be enrolled in a Medicare Advantage plan and a stand-alone prescription drug plan (PDP) at the same time.

B enefits

Transferring Prescriptions Made Easy

You can transfer your prescriptions to a different in-network pharmacy. Many pharmacies let you transfer prescriptions over the phone, online or in person. Just make sure the new pharmacy is still in network. Remember, when transferring prescriptions, don’t wait until the last minute.

Tier 1 Generics

Get access to low-cost Tier 1 generics. Cost varies by plan.

Limit your trips to the pharmacy with our convenient mail-order benefit. With this benefit, you can get a 90day supply of your drugs delivered directly to you.

If you prefer to get your drugs at a retail pharmacy, you can visit any in-network pharmacy and get a 90-day supply of drugs on Tiers 1 – 4 for three copays or coinsurance on Tier 4 depending on the plan benefits.

Medication Therapy Management

If you take multiple medications, this program can help you use them safely and effectively.

Extra Help

You might be able to get help paying for your prescription drug premiums and costs through the Extra Help program. To see if you qualify, call one of the following:

• (800) MEDICARE (800-633-4227), 24 hours a day, seven days a week (TTY 877-486-2048).

• The Social Security Administration at (800) 772-1213, 7 a.m. to 7 p.m., Monday through Friday (TTY 800-325-0778).

• The state’s Medicaid office.

Stages of Pharmacy Coverage

There are three pharmacy coverage stages, but most people stay in the initial coverage stage.

Most people stay in this stage.

Few people reach this stage.

Even fewer people reach this stage.

Initial Coverage

You pay the copay as outlined in your Summary of Benefits until the amount you pay plus the amount we pay reaches $5,030.

Coverage Gap

Also known as the “donut hole,” this stage begins when the amount you pay plus the amount we pay for your prescription drugs reaches $5,030. Here, you pay the following until your out-of-pocket expenses reach $8,000:

• Your copay for Tier 1 drugs.

• 25% for Tier 2 through Tier 5.

Catastrophic Coverage

This stage begins when your out-of-pocket drug costs reach $8,000. Once you reach this stage, as a FirstMedicare Direct member, your drug cost-share will be $0 for the rest of the year.

Hometown People Focused on You

We do more than help you when you’re sick. We help you stay healthy in the first place, so you have a team of health coaches, care coordinators and more to help you with both.

Care Coordinators

Whether you’d like to speak to a dietitian, want to quit smoking or need help understanding a recent diagnosis, we have teams to help you achieve your goals or get you back on track.

Connect to a team of providers, like nurse practitioners, social workers, health coaches, dietitians, pharmacists and more, who work with

your doctor to make sure you have the resources you need to stay healthy or work through your medical issues.

The care coordination team reaches out to offer these services, but you can also request them if you’d like this personalized help.

We like to get out and meet the entire community. We’ll be at health fairs, senior expos and other events ready to educate and talk with you and others throughout the area. Led by our team of liaisons, we’re excited to get to know you.

Craig Alford Community Liaison

Lora Felger Community Liaison

Hometown Coverage Away from Home

No matter where sickness or injury strikes – even if you’re traveling – you’re covered for emergency care, urgent care (also called convenient care or a walk-in clinic) or an ambulance at the in-network cost-share amount.

You’re also covered at the in-network cost-share if you’re admitted to a hospital through the emergency department.

You have out-of-network coverage for routine care too, but you typically pay less when staying in network.

How You’re Covered

•  Break your ankle while hiking? Your emergency care is covered both in and out of network, and so is any emergency surgery you need as a result.

•  Need a routine physical? You’re covered, but you might pay more when you’re out of network.

•  Come down with a cold or flu? Urgent care (also called convenient care or a walk-in clinic) is covered at the in-network level regardless of where you get your care. Worldwide emergency and urgent care is also available.

If you have questions about other situations, give us a call.

Helpful Travel Reminders

Your plan includes perks that can make your travel easier, like the 24-hour Nurse Advice Line and virtual health coverage.

Assist America®

Have peace of mind whenever you travel 100 miles or more from home. With doctors, nurses and emergency medical technicians on staff, help is just a phone call away, 24 hours a day and 365 days a year.

Assist America can connect you to prompt medical attention and help make sure you’re admitted to reliable hospitals when needed. Plus, it can even help in some situations that aren’t health-related.

Here are just some of its many features:

•  Prescription assistance if you need medication or left your prescription behind.

•  Compassionate visit from someone close to you if you need to be hospitalized for more than a week.

•  Return of mortal remains.

•  Medical referrals.

•  Emergency medical evacuation.

•  Help returning home if you need medical care to travel.

•  Lost luggage assistance.

•  Interpreter and legal referrals.

Assist America will not pay you back for ambulance and other services you arrange on your own. In a lifethreatening emergency, always call the ambulance right away. There is no added cost for the service itself, but there could still be a cost with any medical care. Other conditions and exclusions may apply.

Perks and Programs

Your plan offers plenty of perks and programs to help you meet your health goals.

Dental

We cover up to $3,000 a year for use on dental services, like cleanings, X-rays and more at in-network providers.

You may have a copay or coinsurance for some dental services. Check your Summary of Benefits.

Vision

Get access to vision services beyond what Original Medicare covers, including a routine vision exam with an in-network provider. Plus, get a $200 allowance for eyewear. (PPO Plus has a $130 allowance). See enclosed flier for more information on how to use this benefit.

Be Fit

Get the most out of your fitness activities with Be Fit. You get to choose how you want to work out, and your $360-per-year benefit will cover the costs.

Activities include the following and more:

•  Fitness class fees.

•  Gym memberships.

•  Online fitness subscriptions.

• Weight loss subscriptions.

•  Ski memberships.

•  Rowing.

•  Golf.

•  Bowling.

• Tennis.

•  Pickleball.

•  Recreational league fees.

•  Pool exercise classes.

•  5K/10K race fees.

If your fees are more than $360 a year, you pay the difference. Be Fit doesn’t cover fitness trackers or personal equipment. See enclosed flier for more information on how to use this benefit.

OTC Benefit

Save money with the new over-the-counter supplemental benefit from FirstMedicare Direct. This program gives you an allowance of up to $140/year ($35 every three months, with no rollover) for commonly used OTC products. Members can use their allowance to purchase products online and at participating retailers from many categories including but not limited to:

•  Cold, flu and allergy.

•  Dental and denture care.

•  Diabetes care.

•  Eye and ear care.

•  First aid and medical supplies.

•  Personal care.

•  Sleep aids.

Allowance amounts may vary based on plan type and service area.

Not available for FirstMedicare Direct PPO Plus.

Hearing Benefit

Through TruHearing®, you can get one routine hearing exam for a $0 copay and lowered rates on up to two TruHearing hearing aids per year when you see a TruHearing provider.

Companion Benefit

Get up to 30 hours of in-home support yearly through the Papa Pal program. This service gives you access to a friendly companion who can help you with a variety of tasks. Plus, they can be a fun person to chat with. And they can go with you to places like a library, park, doctor’s office, pharmacy and more.

Services include:

•  Companionship (like playing games, eating lunch or having a conversation).

• Transportation.

• Technical support (like setting up streaming platforms or teaching you how to make a video call).

•  Light help around the house.

•  Light exercise.

•  Grocery shopping.

•  Help with your pet.

Services are typically provided in one-hour increments.

Virtual Health Coverage

Get care when and where you need it with virtual health coverage. If you need to interact with your primary care provider (PCP) or specialist over the phone or online, you’re covered through the telehealth benefit. You don’t even need to leave the comfort of your home. Copayment may apply.

You can also get care for common conditions like allergies, cold, flu and pink eye from anywhere you have phone or internet connection in the U.S with FirstHealth On the Go. Visits through FirstHealth On the Go are a $0 copay. Whether at home or traveling, you can talk to a board certified doctor by phone or secure video through the On the Go app or FirstHealthOnTheGo.org at any time of the day, any day of the year. Go to FirstHealthOnTheGo.org to log in and get started.

Virtual Primary Care

Your time is valuable. And so is your health. Virtual Primary Care lets you prioritize both. With the Virtual Primary Care program from MDLIVE, you can get virtual care from a primary care provider at MDLIVE for routine wellness visits, preventive care and chronic care. Get unlimited visits at no additional cost.

With Virtual Primary Care, your routine preventive wellness screenings include:

•  Medication refills for a year.

•  Routine lab testing.

•  Health risk assessment.

•  Preventive care recommendations.

•  Referrals to specialists.

•  Low-cost prescriptions.

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And get routine care for chronic conditions:

• Type 2 diabetes.

•  High cholesterol.

•  High blood pressure.

•  Obesity.

• Thyroid problems.

• Asthma and COPD.

Get unlimited visits at no additional cost. Enroll in this program by calling MDLIVE at (800) 400-6354.

Nurse Advice Line

Get access to healthcare information, 24 hours a day, seven days a week, with the Nurse Advice Line. Specially trained nurses help you with your health questions at no cost.

The Nurse Advice Line can help you decide what kind of care to seek – whether you can treat the condition at home, need to see your doctor, or need urgent or immediate care. The toll‐free Nurse Advice Line is on the back of your FirstMedicare Direct identification card.

Disease Management Programs

Get connected to resources, motivation, support and reminders to help you manage the following and more:

• Asthma.

•  Diabetes.

•  High blood pressure.

•  Congestive heart failure.

•  Migraines.

Preventive Care

Focus on preventing sickness and catching problems before they get worse with these services and more:

• Yearly wellness visit.

•  Routine screenings, like mammograms or colorectal cancer screenings.

•  Flu shot.

Your Health at Your Fingertips

We value giving you the member experience you deserve with a variety of options to fit your busy lifestyle – and as a member of our health plan, you get access to our comprehensive suite of health and wellness resources, programs, perks and offerings. We call this Hally ® health.

Hally health is your ally in your wellness journey. Whenever you see the word “Hally,” it’s us at your health plan connecting you with a resource or support that’ll help you live your healthiest life.

As a member, you also get secure, instant access to your health insurance coverage by logging in to your Hally account through the MyChart app or on hally.com. Review your plan coverage, discover resources and support for your health conditions, and find the care you need anytime, anywhere.

Find helpful tools at hally.com.

Get access to a wealth of resources to help you stay healthy – with no login required. At hally.com, you’ll find:

•  Health tools, tips and resources.

• Access to our quarterly “Simply Well” newsletter.

•  Hally Healthcast , a monthly podcast led by medical experts who discuss common health and wellness topics.

•  Free online fitness and cooking classes.

•  Hally health blog, featuring informational articles and healthy tips for the entire family.

• Tasty recipes that’ll help you eat healthier.

Appeals and Grievances

Medicare Advantage plans offer safeguards to make sure you’re treated fairly and have the chance to voice your opinion if you think you’ve been mistreated.

Appeal

This is a type of complaint you can file if you disagree with the plan’s decision to not cover healthcare services you’re trying to get or have already gotten.

You must file an appeal in writing within 60 days of the decision or as soon as you can.

Grievance

This is a type of complaint you can make about your plan. Some examples are poor quality of care, bad customer service or feeling like an employee is encouraging you to leave the plan.

You can file a grievance by calling our Member Services department within 60 days of the event or as soon as you can.

Enrollment Timelines and Requirements

The Centers for Medicare & Medicaid Services (CMS) sets certain times during the year when you can enroll in a Medicare Advantage or prescription drug plan.

Timelines and Requirements

Annual Enrollment Period

From October 15 to December 7, you can enroll in Medicare Advantage or a stand-alone prescription drug plan, or you can switch plans. If you enroll during this period, your coverage begins January 1 of the following year.

Initial Enrollment Period

You have a seven-month initial enrollment period to enroll in Original Medicare, Medicare Advantage or a prescription drug plan. It starts three months before the month you turn 65, includes the month of your 65th birthday and ends three months after the month you turn 65.

• If you enroll one to three months before your 65th birthday, your coverage begins the first day of the month you turn 65.

• If you enroll during your birth month, your coverage begins the first day of the following month.

• If you enroll one to three months after the month you turn 65, your coverage begins the first day of the month after you enroll.

Open Enrollment Period

From January 1 to March 31, if you’re already on a Medicare Advantage plan, you can switch to Original Medicare (and join a stand-alone prescription drug plan). Or you can switch from one Medicare Advantage plan to another.

Special Enrollment Period

You can enroll in a new plan or change your plan in certain situations. Examples include:

• Permanent address change.

• Loss of coverage due to employment change.

• Becoming eligible for a low-income subsidy. Contact us for other situations that qualify.

To be eligible for our plans, you must:

• Have Medicare Parts A and B and live in the service area at least six months of the year.

• Continue to pay your Medicare Part B premium if not otherwise paid for by Social Security or another third party.

Enrollment in a plan will automatically disenroll you from any other Medicare Advantage plan. But it won’t automatically disenroll you from a Medicare Supplement plan. You must contact that plan to disenroll.

Enrollment Process

How to Enroll

Online

Go to FirstMedicare.com to get started.

By Phone

Call (888) 382-9781 (TTY 711), daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30.

By Mail

Fill out and mail us the enrollment form in the back of this guide. You can also download it from FirstMedicare.com.

Mail to:

FirstMedicare Direct

Application Processing Center

3310 Fields South Dr. Champaign, IL 61822

Broker

If you attend a seminar, the person presenting can schedule an appointment to help you enroll.

After You Enroll

If you enroll in a Medicare Advantage plan during the Annual Enrollment Period, your coverage will begin January 1, 2024. In the meantime, we’ll mail you your member materials and your member ID card, which you’ll use instead of your red, white and blue Medicare card at the doctor, hospital and pharmacy starting January 1.

Meet us in our local office. Stop by our office for a face-to-face visit. We look forward to meeting you.

FirstMedicare Direct

1930 N. Poplar St., Suite 21 Southern Pines, NC 28387

Hometown Plans

You deserve coverage that fits your lifestyle, so we offer plans made for your needs.

Point of Service (HMO-POS)

•  Comfort of having an in-network primary care provider to oversee all your care.

•  Flexibility to see out-of-network providers but may save money by staying in network.

•  Balance between security and freedom.

Preferred Provider Organization (PPO)

•  Not required to choose a primary care provider but can if you wish.

•  Flexibility to see out-of-network providers but may save money by staying in network.

•  Focus on freedom and access.

Find an overview of your plan options and benefits made for you in our 2024 Key Medicare Advantage Benefits guide.

HMO-POS Plans

POS plans give you the comfort of having a primary care provider with the freedom to see out-of-network providers.

PPO Plans

PPO plans give you the freedom to go out of network and the flexibility to choose whether you want a primary care provider. These

(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

FirstCarolinaCare Insurance Company’s plans are HMO and PPO plans with a Medicare contract. Enrollment in a FirstCarolinaCare plan depends on contract renewal. You must continue to pay your Medicare Part B premium. Out-ofnetwork/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) 210-9167 (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 (877) 210-9167 (TTY: 711) for more information.

If you would like to shop and enroll, click here.

Sandhills Star Ratings

Click on the link below to view the most up-to-date star ratings for your service area.

2023 FirstMedicare Direct PPO Star Ratings

2024 FirstMedicare Direct PPO Star Ratings (available mid-October 2023)

2023 FirstMedicare Direct HMO Star Ratings

2024 FirstMedicare Direct HMO Star Ratings (available mid -October 2023)