Get more out of Medicare with Medicare Advantage.
Comfort of having an in-network primary care provider to oversee all your care.
Replaces Original Medicare. May cover benefits that Original Medicare doesn’t.
Generally gives you the flexibility to see any doctor who accepts Original Medicare. Supplements Original Medicare. Only covers expenses covered by Original Medicare.
No medical underwriting.
Medical underwriting. (Except for guaranteed issue plans.)
Lower premiums than Medicare Supplement plans.
Who pays in what order: health plan, you. Not age- or tobacco-rated.
Higher premiums than Medicare Advantage plans. Who pays in what order: Original Medicare, health plan, you. Age- and tobacco-rated.
Key: This is a summary of commonly used benefits.
IN means in network, and OON means out of network.
The OON yearly limit includes your combined costs for both in-network and out-of-network 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 network.
Members 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.
** Not available for FirstMedicare Direct PPO Plus.
Dental Coverage
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 Hardware Allowance
Get coverage for one routine eye exam and a $200 allowance for eyewear. (PPO Plus has a $130 allowance).
Be Fit
Get fit with a $360/year benefit to use on a variety of fitness activities.
OTC Benefit**
Save money with the new over-thecounter 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.
Hearing Benefit
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.
Companion Benefit
Get up to 30 hours of in-home support yearly (in one-hour increments).
Ground 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 fixed dollar amount (like $20), and coinsurance is a percentage (like 20%).
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 (Nonpreferred 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: This is the care you receive at an emergency room (ER) or emergency department. When you believe your health is at serious risk, seek emergency department care immediately. Don’t hesitate to call 911 for assistance.
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: A set amount you pay before your plan starts helping pay for your medical care or pharmacy benefits. Our plans don’t have medical deductibles.
Outpatient care: Medical care or treatment that doesn’t include staying overnight in a hospital.
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.
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.
Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
Urgent care: The amount you pay for urgent or convenient care.
Yearly limit: The most you’ll pay in a coverage period before your plan pays 100% of covered expenses. It’s also called the out-of-pocket maximum.
* Review the provider directory at FirstMedicare.com for our in-network doctors and hospitals.
With both POS and PPO, you have the freedom to go out of network. But you likely save money by staying in network.
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-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.
MDUNFC24-SHLfoldguide-0623 • Y0094_24_112602_M