** Cost ** |
Premium and Other Important Information |
$0 monthly plan premium in addition to your monthly Medicare Part B premium. |
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. |
$6 700 out-of-pocket limit. All plan services included. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
No referral required for network doctors specialists and hospitals. |
** Extra Benefits ** |
Over-the-Counter Items |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
This plan does not cover supplemental routine transportation. |
** Important Information ** |
Premium and Other Important Information |
$0 monthly plan premium in addition to your monthly Medicare Part B premium. |
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. |
$6 700 out-of-pocket limit. All plan services included. |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
No referral required for network doctors specialists and hospitals. |
** Inpatient Care ** |
Inpatient Hospital Care |
No limit to the number of days covered by the plan each hospital stay. |
$0 copay |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
Inpatient Mental Health Care |
$0 copay |
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
Skilled Nursing Facility (SNF) |
Authorization rules may apply. |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
$0 copay for SNF services |
Home Health Care |
Authorization rules may apply. |
$0 copay for Medicare-covered home health visits |
Hospice |
You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice. |
** Outpatient Care ** |
Doctor Office Visits |
$0 copay for each primary care doctor visit for Medicare-covered benefits. |
$2 copay for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
$0 copay for: Medicare-covered chiropractic visits |
up to 1 supplemental routine visit(s) every year |
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. |
Podiatry Services |
$0 copay for Medicare-covered podiatry visits |
up to 8 supplemental routine visit(s) every year |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$0 copay for Medicare-covered Mental Health visits |
$0 copay for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
$0 copay for Medicare-covered visits |
Outpatient Services/Surgery |
Authorization rules may apply. |
$0 copay for each Medicare-covered ambulatory surgical center visit |
$0 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
Authorization rules may apply. |
$0 copay for Medicare-covered ambulance benefits. |
Emergency Care |
$40 copay for Medicare-covered emergency room visits |
Worldwide coverage. |
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit. |
Urgently Needed Care |
$0 copay for Medicare-covered urgently-needed-care visits |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
$0 copay for Medicare-covered Occupational Therapy visits |
$0 copay for Medicare-covered Physical and/or Speech and Language Therapy visits |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
10% of the cost for Medicare-covered items |
Prosthetic Devices |
Authorization rules may apply. |
10% of the cost for Medicare-covered items |
Diabetes Programs and Supplies |
Authorization rules may apply. |
$0 copay for Diabetes self-management training |
$0 copay for: |
Diabetes monitoring supplies |
Therapeutic shoes or inserts |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
Authorization rules may apply. |
$0 copay for Medicare-covered: |
lab services |
diagnostic procedures and tests |
X-rays |
diagnostic radiology services (not including X-rays) |
therapeutic radiology services |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
Authorization rules may apply. |
$0 copay for: |
Medicare-covered Cardiac Rehabilitation Services |
Medicare-covered Intensive Cardiac Rehabilitation Services |
Medicare-covered Pulmonary Rehabilitation Services |
Preventive Services and Wellness/Education Programs |
$0 copay for all preventive services covered under Original Medicare at zero cost sharing: Abdominal Aortic Aneurysm screening Bone Mass Measurement Cardiovascular Screening Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam) Colorectal Cancer Screening Diabetes Screening Influenza Vaccine Hepatitis B Vaccine HIV Screening Breast Cancer Screening (Mammogram) Medical Nutrition Therapy Services Personalized Prevention Plan Services (Annual Wellness Visits) Pneumococcal Vaccine Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only) Smoking Cessation (Counseling to stop smoking) Welcome to Medicare Physical Exam (Initial Preventive Physical Exam) |
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Please contact plan for details. |
The plan covers the following supplemental education/wellness programs: |
Nursing Hotline |
Kidney Disease and Conditions |
$0 copay for renal dialysis |
$0 copay for kidney disease education services |
Outpatient Prescription Drugs |
$0 copay for Part B-covered drugs. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.firstpluspr.com on the web. |
Different out-of-pocket costs may apply for people who have limited incomes live in long term care facilities or have access to Indian/Tribal/Urban (Indian Health Service) providers. |
The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). |
Total yearly drug costs are the total drug costs paid by both you and a Part D plan. |
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. |
Some drugs have quantity limits. |
Your provider must get prior authorization from First+Plus Complete (HMO SNP) for certain drugs. |
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. |
If you request a formulary exception for a drug and First+Plus Complete (HMO SNP) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug. |
$0 deductible. |
You pay the following until total yearly drug costs reach $2 930: |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$4 copay for a one-month (30-day) supply of drugs in this tier |
$20 copay for a one-month (30-day) supply of drugs in this tier |
$40 copay for a one-month (30-day) supply of drugs in this tier |
25% coinsurance for a one-month (30-day) supply of drugs in this tier |
$12 copay for a three-month (90-day) supply of drugs in this tier |
$60 copay for a three-month (90-day) supply of drugs in this tier |
$120 copay for a three-month (90-day) supply of drugs in this tier |
25% coinsurance for a three-month (90-day) supply of drugs in this tier |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$4 copay for a one-month (31-day) supply of drugs in this tier |
$20 copay for a one-month (31-day) supply of drugs in this tier |
$40 copay for a one-month (31-day) supply of drugs in this tier |
25% coinsurance for a one-month (31-day) supply of drugs in this tier |
The plan covers all formulary generics (100% of formulary generic drugs) through the coverage gap. |
You pay the following: |
Tier 1: Generic Drugs |
$4 copay for a one-month (30-day) supply of all drugs covered in this tier |
$12 copay for a three-month (90-day) supply of all drugs covered in this tier |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Tier 1: Generic Drugs |
$4 copay for a one-month (31-day) supply of all drugs covered in this tier |
After your total yearly drug costs reach $2 930 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 86% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 700. |
After your yearly out-of-pocket drug costs reach $4 700 you pay the greater of: 5% coinsurance or $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs. |
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from First+Plus Complete (HMO SNP). |
You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 930: |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$4 copay for a one-month (30-day) supply of drugs in this tier |
$20 copay for a one-month (30-day) supply of drugs in this tier |
$40 copay for a one-month (30-day) supply of drugs in this tier |
25% coinsurance for a one-month (30-day) supply of drugs in this tier |
You will be reimbursed for these drugs purchased out-of-network up to the plan's cost of the drug minus the following: |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$4 copay for a one-month (30-day) supply of all drugs covered in this tier |
You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700. You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700. |
You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700. You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700. |
You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700. You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 700. |
After your yearly out-of-pocket drug costs reach $4 700 you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share which is the greater of: 5% coinsurance or $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs. |
Dental Services |
$0 copay for Medicare-covered dental benefits |
$0 copay for the following preventive dental benefits: |
up to 1 oral exam(s) every six months |
up to 1 cleaning(s) every six months |
up to 1 dental x-ray(s) every year |
Plan offers additional comprehensive dental benefits. |
$600 plan coverage limit for comprehensive dental benefits every year |
Hearing Services |
$0 copay for Medicare-covered diagnostic hearing exams |
$0 copay for |
up to 1 supplemental routine hearing exam(s) every year |
fitting-evaluations for a hearing aid |
$0 copay for hearing aids. |
$300 plan coverage limit for hearing aids every three years. |
** Additional Benefits ** |
Vision Services |
$0 copay for diagnosis and treatment for diseases and conditions of the eye |
and up to 1 supplemental routine eye exam(s) every year |
$0 copay for one pair of eyeglasses or contact lenses after cataract surgery |
up to 1 pair(s) of glasses every year |
up to 1 pair(s) of contacts every year |
$100 plan coverage limit for eye wear every year. |
Over-the-Counter Items |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
This plan does not cover supplemental routine transportation. |
Acupuncture |
This plan does not cover Acupuncture. |
** Inpatient Care ** |
Inpatient Hospital Care |
No limit to the number of days covered by the plan each hospital stay. |
$0 copay |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
** Outpatient Care ** |
Doctor Office Visits |
$0 copay for each primary care doctor visit for Medicare-covered benefits. |
$2 copay for each specialist visit for Medicare-covered benefits. |
Outpatient Services/Surgery |
Authorization rules may apply. |
$0 copay for each Medicare-covered ambulatory surgical center visit |
$0 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
Authorization rules may apply. |
$0 copay for Medicare-covered ambulance benefits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
10% of the cost for Medicare-covered items |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
Authorization rules may apply. |
$0 copay for Medicare-covered: |
lab services |
diagnostic procedures and tests |
X-rays |
diagnostic radiology services (not including X-rays) |
therapeutic radiology services |
** Additional Benefits ** |
Over-the-Counter Items |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
This plan does not cover supplemental routine transportation. |