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. (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 2023 Medicare Advantage Key Benefits Guide Western North Carolina
Get more out of Medicare with Medicare Advantage. Replacescare.Original
Medicare Advantage vs. Medicare Supplement
Comfort of having an in-network primary care provider to oversee all your
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 Advantage Medicare Supplement
Dental Coverage
Assist America
OTC4Me
Get coverage for one routine eye exam and a $130 allowance for eyewear.
+ Also called convenient or walk-in care.
Membersnetwork.on
Be Fit
& Dollar amounts listed for inpatient hospital care and SNF are amounts you pay per day.
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.
Get fit with a $360/year reimbursement on a variety of fitness activities. Coordination
Get
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 1 2 3 4 5 6 Plan Costs Office Visits DiagnosticServices Emergency Services Hospital Services Initial Rx Coverage (for 30-day supply) Plan Type Network Premium DeductibleMedical Yearly Limit (does not pharmacy)include PCP Visit SpecialistVisit VisitVirtual TherapyPhysical Chiropractic Lab X-Ray CT/MRI Ambulance» Care***Emergency Urgent Care+ CareHospitalOutpatient Inpatient Hospital Care^& services(includingreceived) 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 Standard (HMO-POS) IN $0 $0 $5,250 $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 $150 (Tiers 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% 2 FirstMedicare Direct POS Plus (HMO-POS) IN $39 $0 $3,300 $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%
Connect to a team of providers who work with your doctor to make sure you have the resources you need. Benefit up to 30 hours of in-home support yearly (in one-hour increments).
Care
Key: This is a summary of
Get expert medical help when you’re 100 miles or more from home.
commonly used benefits.
Perks and
*** Emergency care available worldwide.
Vision Coverage
You may have a copay or coinsurance for some dental services. Check your Summary of Benefits.
» Non-emergency cost-sharing may vary. Contact the plan for details.
Get 10% off on over-the-counter (OTC) products online or by phone.
IN means in network, and OON means out of network.
Hearing Benefit
^ You pay nothing for days 91 and beyond in
POS plans may pay more for preventive care out of network.
The OON yearly limit includes your combined costs for both in-network and out-of-network care.
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.
Companion
Programs
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%).
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.*
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.
Inpatient hospital care: The amount you pay for a stay in an in-network hospital.*
Urgent care: The amount you pay for urgent or convenient care.
Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
• Tier 4 (Non-Preferred Drug).
• Tier 5 (Specialty Tier).
• Tier 3 (Preferred Brand).
Lab: What you pay for lab services, like blood tests.
Ambulance: What you pay for an ambulance ride in an emergency.
• Tier 2 (Generic).
Medical deductible: What you pay out-of-pocket before your coverage starts. Our plans don’t have medical deductibles.
Helpful Terms
Outpatient surgery: What you pay for an outpatient procedure.
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.
• Tier 1 (Preferred Generic).
Drug tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups:
* Review the provider directory at FirstMedicare.com for our in-network doctors and hospitals.
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.
Skilled nursing facility (SNF): What you pay for an approved stay at a SNF.
With a POS plan, you have the freedom to go out of network. You save money by staying in network.
Emergency care: The amount you pay for emergency care, like a trip to the emergency department.
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. MDUNFC23-WNCfoldguide-0622 • H6306_23_108830_M Western North Carolina