(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
2023 Hometown Medicare Advantage
Key Benefits Guide
North Carolina Sandhills
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.
Medicare Advantage vs. Medicare Supplement
Advantage. Comfort of having an in-network primary care provider to oversee all your Replacescare.Original Medicare. May cover benefits that Original Medicare doesn’t. No medical underwriting. Lower premiums than Medicare Supplement plans. Who pays in what order: health plan, you. Not age- or tobacco-rated. Generally gives you the flexibility to see any doctor who accepts Original SupplementsMedicare. Original Medicare.Onlycovers expenses covered by Original Medicare. Medical underwriting. (except for guaranteed issue plans) Higher premiums than Medicare Advantage plans. Who pays in what order: Original Medicare, health plan, you. Age- and tobacco-rated. Medicare
Get More out of Medicare with Medicare Advantage Medicare Supplement
Dental Coverage
Connect to a team of providers who work with your doctor to make sure you have the resources you need
Assist America®
Key: This is a summary of commonly used benefits.
OTC4Me
We cover up to $3,000 a year for use on dental services, like cleanings, X-rays and more. You pay the dentist and then send us the receipt. If your dentist submits the claim for you, you don’t need to send us the receipt. There’s no set network, so you can go to any dentist you choose.
Get one routine hearing exam for a $0 copay when you see a TruHearing® provider and lowered rates on up to two TruHearing hearing aids per year.
Care Coordination
Get fit with a reimbursement$360/yearonavariety of fitness activities, such as golf, pickleball and gym memberships.
Be Fit
Get 10% off on over-the-counter (OTC) products online or by phone
Hearing Benefit
IN means in network, and OON means out of network.
Hometown Perks and Programs
You may have a copay or coinsurance for some dental services. Check your Summary of Benefits.
Get up to 30 hours of in-home support yearly (in one-hour increments).
Companion Benefit
care. » 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 Membersnetwork.on POS plans may pay more for preventive care out of network. & Dollar amounts listed for inpatient hospital care and SNF are amounts you pay per day. 1 2 3 4 5 6 Plan Costs Office Visits DiagnosticServices Emergency Services Hospital Services Initial Rx Coverage (for 30-day supply; applies only to Rx plans) Plan Type Network Premium DeductibleMedical Yearly Limit (does not pharmacy)include PCP Visit VisitSpecialist VisitVirtual TherapyPhysical Chiropractic Lab X-Ray CT/MRI Ambulance» Care***Emergency Urgent Care+ HospitalOutpatientCare Inpatient Hospital Care^& (including services received) Skilled Nursing Facility& (noncustodial care based on medical necessity) Rx Deductible Rx Cost by Tier Rx Gap Coverage 1 2 3 4 5 1 FirstMedicare Direct POS (HMO-POS)Plus IN $35 $0 $3,250 $0 $35 $0 $30 $20 $0 $0 $250 $250 $125 $10 $250 $295 Days 1-6; $0 Days 7+ $0 Days 1-20; $196 Days 21-100 $0 $2 $15 $47 50% 33% Tier 1 Drugs Covered Through the Coverage GapOON $5,450 30% $65 $0 30% 30% 30% 30% 30% $250 $125 $10 30% 30% 30% 2 FirstMedicare Direct POS (HMO-POS)Choice IN $0 $0 $5,000 $0 $30 $0 $30 $20 $0 $0 $275 $350 $110 $10 $250 $295 Days 1-6; $0 Days 7+ $0 Days 1-20; $196 Days 21-100 No Pharmacy Coverage OON $8,950 30% $65 $0 30% 30% 30% 30% 30% $350 $110 $10 30% 30% 30% 3 FirstMedicare Direct POS (HMO-POS)Standard IN $0 $0 $4,200 $5 $35 $0 $30 $20 $0 $0 $275 $350 $110 $20 $300 $325 Days 1-6; $0 Days 7+ $0 Days 1-20; $196 Days 21-100 (Tiers$150 3, 4, 5) $5 $20 $47 $100 30% Tier 1 Drugs Covered Through the Coverage GapOON $8,950 30% $65 $0 30% 30% 30% 30% 30% $350 $110 $20 30% 30% 30% 4 FirstMedicare Direct PPO Plus (PPO) IN $59 $0 $4,200 $10 $25 $0 $30 $20 $0 $0 $250 $350 $110 $15 $275 $310 Days 1-6; $0 Days 7+ $0 Days 1-20; $196 Days 21-100 $0 $2 $15 $47 45% 33% Tier 1 Drugs Covered Through the Coverage GapOON $8,950 20% 20% $0 20% 20% 30% 30% 30% $350 $110 $15 20% 20% 20% Telehealth Benefit Connect with your primary care provider or specialist over the phone or online without the inconvenience of going to the doctor’s office or sitting in a waiting room. Copayment may apply. Virtual Visits Talk to a board certified doctor or counselor by phone or secure video through hally.com, 24/7. Virtual Health Coverage
Get coverage for one routine eye exam and a $130 allowance for eyewear.
Get expert medical help when you’re 100 miles or more from home.
Vision Coverage
The OON yearly limit includes your combined costs for both in-network and out-of-network
Emergency care: The amount you pay for emergency care, like a trip to the emergency department.
Outpatient surgery: What you pay for an outpatient procedure.
• Tier 5 (Specialty Tier).
Skilled nursing facility (SNF): What you pay for an approved stay at a SNF.
* Review the provider directory at FirstMedicare.com for our in-network doctors and hospitals.
Drug tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups:
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
• Tier 1 (Preferred Generic).
Urgent care: The amount you pay for urgent or convenient care.
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.
• Tier 3 (Preferred Brand).
Lab: What you pay for lab services, like blood tests.
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.
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%).
Medical deductible: What you pay out-of-pocket before your coverage starts. Our plans don’t have medical deductibles.
• Tier 2 (Generic).
Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
With both a POS and PPO, you have the freedom to go out of network. You save money by staying in network.
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.*
Helpful Terms
• Tier 4 (Non-Preferred Drug).
Inpatient hospital care: The amount you pay for a stay in an in-network hospital.*
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.
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 (888) 382-9781 (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. MDUNFC23-SHLfoldguide-0622 • Y0094_23_108829_M North Carolina Sandhills