Key Benefits Guide
2023 Medicare Advantage
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. (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 North Carolina Triangle
Medicare Advantage vs. Medicare Supplement
Get More out of Medicare with Medicare 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 OnlyMedicare.covers 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 Advantage Medicare Supplement
Vision Coverage
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. & 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) Plan Network Premium DeductibleMedical Yearly Limit (does not include pharmacy) PCP Visit VisitSpecialist TherapyPhysical Chiropractic Lab X-Ray CT/MRI Ambulance» Emergency Care*** 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 SmartHMO (HMO) IN $0 $0 $2,900 $0 $35 $10 $10 $0 $0 $0 $100 $80 $0 $150 $150 Days 1-5; $0 Days 6-90 $0 Days 1-20; $100 Days 21-100 $0 $0 $10 $47 $100 33% Tier 1 Drugs Covered Through the Coverage Gap Perks and Programs Care Coordination
Fitness
Connect to a team of providers who work with your doctor to make sure you have the resources you need.
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. Benefit
Our plan gives you a prepaid card with a benefit of up to $75 a quarter. It allows you to purchase OTC products at participating retailers nationwide and online from a catalog with hundreds of products to choose from.
Dental Coverage
Get covered preventive dental services, including one cleaning and fluoride treatment every six months, and one full set of X-rays every three years. Benefit
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.
OTC
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.
Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
* Review the provider directory at FirstMedicare.com for our in-network doctors and hospitals.
• Tier 2 (Generic).
• Tier 5 (Specialty Tier).
• Tier 1 (Preferred Generic).
Urgent care: The amount you pay for urgent or convenient care.
Lab: What you pay for lab services, like blood tests.
Emergency care: The amount you pay for emergency care, like a trip to the emergency department.
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.
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.
Medical deductible: What you pay out-of-pocket before your coverage starts. Our plans don’t have medical deductibles.
• Tier 4 (Non-Preferred Drug).
Drug tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups:
• Tier 3 (Preferred Brand).
Ambulance: What you pay for an ambulance ride in an emergency.
Helpful Terms
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.
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%).
Inpatient hospital care: The amount you pay for a stay in an in-network hospital.*
Outpatient surgery: What you pay for an outpatient procedure.
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. MDUNFC23-TRGfoldguide-0622 • H6306_23_108824_M North Carolina Triangle