2019 Pre-Enrollment Booklet FirstMedicare Direct Standard ... a Plan... · day, 7 days a week. TTY user should call 1 (877) 486‐2048. If you choose to enroll in a FirstMedicare

2019 Pre-Enrollment BookletFirstMedicare Direct Standard HMO (HMO)

FirstMedicare Direct HMO Plus (HMO)FirstMedicare Direct Plus PPO (PPO)

Service Area includes:Chatham, Hoke, Lee, Montgomery,

Moore, Richmond and Scotland Counties

FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO health plans with

Medicare contracts. Enrollment in FirstMedicare Direct depends on contract renewal.

(877) 279-1732 • www.FirstMedicare.com

Y0094_19221_M_Approved_09/18/2018

Dear Medicare Beneficiary:

For decades, residents in the Sandhills region have trusted FirstHealth of the Carolinas to provide quality health care to the community. FirstHealth and FirstCarolinaCare continue to offer that same quality and local service to Medicare beneficiaries in the Sandhills region through FirstMedicare Direct, a Medicare Advantage plan.

Choosing the right Medicare coverage can seem overwhelming, but our caring and knowledgeable staff are committed to helping you along the path to finding a plan that meets your health care needs. We believe selecting the right health care plan is vital to empowering you to live your best life now.

The information in this booklet will help you explore the benefits of becoming a FirstMedicare Direct member. We encourage you to review the enclosed Summaries of Benefits as they provide detailed information about benefits that our plans offer. If you have questions about anything in this booklet, please do not hesitate to call us at 1 (877) 279‐1732.

Please note that you may enroll in the plan only during specific times of the year, which is explained on the enclosed enrollment form. Benefits and cost sharing may change from year to year.

Beneficiaries with limited income may qualify for Extra Help to pay for prescription drug costs. You may contact your local Social Security office or call 1 (800) MEDICARE ‐ (800) 633‐4227, 24 hours a day, 7 days a week. TTY user should call 1 (877) 486‐2048.

If you choose to enroll in a FirstMedicare Direct plan, you will receive a confirmation of enrollment letter, followed by your new member Welcome kit. The kit will include materials about your plan, including the Evidence of Coverage and information on how to access our prescription drug formulary, provider and pharmacy directories. You also will receive an ID card prior to your effective date.

Thank you for your interest in FirstMedicare Direct, and we look forward to having the opportunity to help you along the path of selecting a health care plan.

Sincerely,

F. Craig Humphrey President FirstCarolinaCare Insurance Company

Y0094_19221_M_Approved_09/18/2018

1

Thank you for your interest in FirstMedicare Direct! We hope this booklet gives you the information you need to make an informed choice. We want to help you pick a plan that works hard for you!

It’s important to understand what options are available to you as a Medicare beneficiary. We encourage you to take the time to review this information and use the tools included to help you make the best choice for your Medicare coverage. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or you may use the Medicare Plan Finder on https://www.medicare.gov.

Inside this booklet, you’ll find --

• Frequently asked questions• Plan Comparison Tool– so you can compare our different options• Summary of Benefits for all three plans we offer — includes details about

what FirstMedicare Direct plans cover and at what cost• Participating Primary Care Providers (Partial Listing)• Star Rating information• Multi-language interpreter services and non-discrimination notice• Enrollment information and application

2

FREQUENTLY ASKED QUESTIONS What is the difference between Medicare Advantage, Part D and Original Medicare?

Original Medicare Part A is hospital coverage that helps cover the costs for inpatient hospital care and skilled nursing facilities (not custodial or long term care), as well as hospice and home health care. Original Medicare Part B covers the costs of doctors’ services, other outpatient care, as well as tests and laboratory services. Medicare Advantage plans offer all the services covered by original Medicare, in addition to some supplemental benefits not covered by Medicare. Medicare drug coverage (Part D) is offered as a separate purchased plan for individuals with Original Medicare. Part D coverage also may be offered with a Medicare Advantage plan for comprehensive coverage. FirstMedicare Direct plans include Parts A and B coverage, plus Part D prescription drug benefits.

Are there any restrictions on what providers I may use?

Many Medicare Advantage plans require you to use network providers in order to be covered, including FirstMedicare Direct HMO plans. However, if you have an emergency you will be covered whether the emergency facility is in or out-of-network. PPO plans allow you the choice of going to a network or out-of-network provider; if you go to an out-of-network provider you may have a higher share of costs.

I already pay for Medicare – why do I have to pay for a Medicare Advantage plan?

Under original Medicare alone, services are not 100% covered and may require significant out-of-pocket costs. Many people enjoy the security of having a plan that limits their total annual out-of-pocket costs in case they should have a significant medical event. Our members also like the fact that FirstMedicare Direct includes a prescription drug benefit.

How do I find out more about FirstMedicare Direct?

If you are considering enrolling, and have questions about benefits, providers or pharmacies or need help with the enrollment process, we have knowledgeable licensed sales representatives who can get you the answers and help you need. Call toll-free at 1-877-279-1732. Hearing impaired persons can call TTY 711.

How do I enroll? 1. You can enroll by phone at the toll free number above 2. You can enroll online by going to

www.FirstMedicare.com and clicking on ENROLL NOW3. You can complete a paper enrollment form4. Medicare beneficiaries may also enroll in any available plan

through the CMS Medicare Online Enrollment Centerlocated at https://www.medicare.gov.

3

Y0094_19301_M_Accepted_08/14/18

2019 Plan Comparison ToolBenefits HMO

Standard HMO Plus PPO Plus Other

Total Monthly Plan Premium

$0 $45 $73

Annual Premium Cost $0 $540 $876

Part C Deductible $0 $0 $0

Part D Deductible $300 $0 $0

Annual Maximum Out-of-Pocket Amount

$6,000 $5,000 In-Network: $5,000

Combined In and Out-of- Network: $10,000

Primary Care Provider $30 copay $15 copay In: $25 copay Out: 20%

coinsurance Specialty Care Provider

$50 copay $50 copay In: $50 copay Out: 20%

coinsurance Inpatient Hospital $300 copay

per day for days 1-6

$0 copay for days 7-90

$295 copay per day for days 1-6

$0 copay for days 7-90

In:$295 copay per day for days 1-6

$0 copay for days 7-90 Out:20%

coinsurance Emergency Care $90 copay $90 copay $90 copay

Urgent Care $30 copay $15 copay $25 copay

Prescription Drugs 30 days at retail Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 6

$10 copay $20 copay $45 copay

$100 copay 25%

$10 copay


$100 copay 33%

$6 copay


$100 copay 33%

$8 copay Fitness Center Membership

$10 a month Included at no cost

Included at no cost

4

5

PREMIUM and BENEFITSFirstMedicare Direct

HMO Plus (HMO) WHAT YOU SHOULD KNOWMonthly Plan Premium YOU PAY $45 You must continue to pay your Medicare

Part B premium.Part C Deductible YOU PAY nothing This plan does not have a medical

deductible.Maximum Out of Pocket $5,000 annually The most you pay for copayments,

coinsurance, and other costs of medical services for the year.

Inpatient Hospital Care1 YOU PAY $295 copayment per day for days 1-6

YOU PAY $0 copayment per day for days 7-90

The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods as defined by Medicare.

Outpatient Hospital Care●Outpatient Surgery or

Ambulatory Surgery Services

●Other Outpatient Services

●Observation Services

YOU PAY $250 copayment per visit



One copayment applies for bilateral cataract surgery if both performed in the same calendar year.

Doctor Visits●Primary Care Physician

●Specialist



Preventive Care Services

Annual Physical Exam

YOU PAY $0 copayment per service

YOU PAY $0 copayment per one annual visit

Includes but not limited to Medicare-covered: glaucoma screening, barium enemas, digital rectal exams, EKG following Welcome Visit.

Emergency Care YOU PAY $90 copayment per visit Copayment waived if admitted within 48 hours.

●SERVICES WITH A1 MAY REQUIRE PRIOR AUTHORIZATION ●

H6306_19112_M Accepted 08/28/2018 6


HMO Plus (HMO) WHAT YOU SHOULD KNOW

Worldwide Emergency Coverage YOU PAY $90 copayment per visit

YOU PAY $400 copayment per one- way transportation (ground or air)

Copayment is NOT waived if you are admitted to the hospital.$10,000 lifetime limit for worldwide emergency coverage outside of the United States.

Urgently Needed Services YOU PAY $15 copayment per visit Copayment is NOT waived if you are admitted to the hospital.

Diagnostic Tests, Lab, Therapeutic

Radiology Services and X-rays1YOU PAY 20% of the total cost Such as MRIs, CT scans, outpatient x-

rays.

Hearing Services YOU PAY $50 copayment per visit Medicare Covered exams to diagnose and treat hearing and balance issues.

Dental Services YOU PAY $50 copayment per visit Medicare Covered dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth).

Vision Services●Medicare Covered Eye

Exam

●Medicare Covered Annual Glaucoma Test

●Post Cataract SurgeryEyewear

●Routine Eye Exam



YOU PAY 20% of the total cost


Diagnose and treat diseases and conditions of the eye.

One pair of eyeglasses or contact lenses after cataract surgery.

Routine Eye Exam annual $130 limit.

Outpatient Mental Health Services YOU PAY $40 copayment Group or individual therapy visits.

H6306_19112_M Accepted 08/28/2018 7



Inpatient Mental Health Care1 YOU PAY $160 copayment per day for days 1-10


Inpatient psychiatric care covers up to 190 days in a lifetime in a psychiatric hospital. This limit does not apply to inpatient mental services provided in a general hospital.

Skilled Nursing Facility (SNF)1 YOU PAY $0 copayment per day for days 1-20


This plan covers 100 days per cause.

Outpatient Rehabilitation Services YOU PAY $40 copayment per visit Occupational, physical, speech and language therapies.

Ambulance1

●Ground Transportation Service

●Air Transportation Service

YOU PAY $250 copayment per one-way transportation


Authorization required for non- emergency services.

Medically necessary Medicare- covered ground or air medical transportation.

Transportation (non-medical) NOT COVERED Non-medical transportation is not a covered service.

Medicare Part B Drugs1 YOU PAY 20% of the total cost

Foot Care (podiatry services) YOU PAY $50 copayment per visit Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions.

Durable Medical Equipment1 YOU PAY 20% of the total cost Includes wheelchairs, oxygen, etc.

Cardiac Rehabilitation YOU PAY $0 copayment per visit Cardiac and Pulmonary rehabilitation visits.

Chiropractic Care YOU PAY $20 copayment per visit Medicare-covered services only.

H6306_19112_M Accepted 08/28/2018 8



Diabetes Supplies and Services●Diabetes monitoring

supplies from Retail Pharmacy

●Diabetes monitoringsupplies from DME supplier

●Diabetesself-managementtraining

●Therapeutic shoesor inserts





Dialysis YOU PAY 20% of the total cost

Home Health Care YOU PAY $0 copayment per visit

Prosthetic devices 1 YOU PAY 20% of the total cost Braces, artificial limbs, etc.

Fitness Center Membership YOU PAY $0 copayment per month Applies to fitness membership at any FirstHealth Center for Health and Fitness. A member may use another plan approved fitness center and be reimbursed up to $300 annually for fees. Reimbursements are made on a quarterly basis and will not be paid in advance.

H6306_19112_M Accepted 08/28/2018 9



Part D Deductible YOU PAY nothing This plan does not have a Part D deductible.

TIERS RETAIL COST MAIL ORDER COST

Tier 1 (Preferred Generic Drugs) YOU PAY $6 copayment YOU PAY $6 copayment

Tier 2 (Generic Drugs) YOU PAY $18 copayment YOU PAY $18 copayment

Tier 3 (Preferred Brand Drugs) YOU PAY $45 copayment YOU PAY $45 copayment

Tier 4 (Non-Preferred Drugs) YOU PAY $100 copayment YOU PAY $100 copayment

Tier 5 (Specialty Drugs) YOU PAY 33% of the total cost YOU PAY 33% of the total cost

Tier 6 (Select Care Drugs) YOU PAY $6 copayment YOU PAY $6 copayment



Tier 3 (Preferred Brand Drugs) YOU PAY $135 copayment YOU PAY $112.50 copayment


Tier 5 (Specialty Drugs) A long term supply is not available inTier 5.

A long term supply is not available in Tier 5.


PRESCRIPTION DRUGS

One month (30 day) supply dispensed

Long Term (90 day) supply dispensed

Cost-sharing may change depending when you enter another phase of the Part D benefit. For more information on the phases of drug coverage, please call us or access our Evidence of Coverage, Chapter 6, at our website

www.FirstMedicare.com.

H6306_19112_M Accepted 08/28/2018 10

To locate our Evidence of Coverage, visit our FirstMedicare Direct website at: www.FirstMedicare.com; choose “Your County” (e.g. Buncombe, Moore, Wake, etc.); select the “Members” tab; choose “Coverage Documents” and click on the 2019 Evidence of Coverage for your plan.

This information is not a complete description of benefits. For more information, if you are a member, please call Member Services toll free at 1-844-201- 4957 (TTY users call 711). If you are not a member call us toll free at 1-877-279-1732. From October 1 to March 31, you can call 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern. From April 1 to September 30, you can call Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern. Or you can visit us at www.FirstMedicare.com.

You can search our plan’s provider and pharmacy directories on our website at www.FirstMedicare.com.

We cover Part D drugs. In addition we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website at www.FirstMedicare.com.

More information about your options under Medicare is available through the Medicare publication, “Medicare and You”. You can get it at the Medicare website (https://www.medicare.gov) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

11H6306_19112_M Accepted 08/28/2018

12

PREMIUM and BENEFITSFirstMedicare Direct HMO Standard(HMO) WHAT YOU SHOULD KNOW

Monthly Plan Premium YOU PAY $0 You must continue to pay your Medicare Part C Deductible YOU PAY nothing This plan does not have a medical Maximum Out of Pocket $6,000 annually The most you pay for Copayments,

coinsurance, and other costs of medical services for the year.

Inpatient Hospital Care1 YOU PAY $300 copayment per day for days 1-6YOU PAY $0 copayment per day for days 7-90

The Copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods as defined by Medicare.

Outpatient Hospital Care●Outpatient Surgery or Ambulatory

Surgery Services

●Other Outpatient Services





One copayment applies for bilateral cataract surgery if both performed in the same calendar year.


●Specialist







Includes but not limited to Medicare-covered: glaucoma screening, diabetes self- management training, barium enemas, digital rectal exams, and EKG following Welcome Visit.

Emergency Care YOU PAY $90 copayment per visit Copayment waived if admitted within 48 hours.

Worldwide Emergency Coverage YOU PAY $90 copayment per visit


Copayment is NOT waived if you are admitted to the hospital.

$10,000 lifetime limit for worldwide emergency coverage outside of the United States.

Urgently Needed Services YOU PAY $30 copayment per visit Copayment is NOT waived if you are admitted to the hospital.

Diagnostic Tests, Lab, Therapeutic

Radiology Services and X-rays1YOU PAY 20% of the total cost Such as MRIs, CT scans, outpatient

x-rays.

Hearing Services YOU PAY $50 copayment per visit Medicare Covered exams to diagnose and treat hearing and balance issues.

●SERVICES WITH A1 MAY REQUIRE PRIOR AUTHORIZATION●

H6306_19113_M_Accepted_08/28/2018 13


Dental Services YOU PAY $50 copayment per visit Medicare Covered dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth).

Vision Services●Medicare Covered Eye Exam

●Medicare Covered Annual Glaucoma Test

●Post Cataract Surgery Eyewear

●Routine Eye Exam




YOU PAY $50 per visit

Diagnose and treat diseases and conditions of the eye.

One pair of eyeglasses or contact lenses after cataract surgery.


Outpatient Mental Health Services YOU PAY $40 copayment per visit Group or individual therapy visits.



Inpatient psychiatric care covers up to 190 days in a lifetime in a psychiatric hospital.

This limit does not apply to inpatient mental services provided in a general hospital.




Outpatient Rehabilitation Services YOU PAY $40 copayment per visit Occupational, physical, speech and language therapies.

Ambulance1


●Air Transportation Service



Cost sharing applies to each one-way trip. Authorization required for non- emergency services.Medically necessary Medicare- covered ground or air medical transportation.

Transportation (non-medical) NOT COVERED Non-medical transportation is not a covered service.

Medicare Part B Drugs1 YOU PAY 20% of the total cost

H6306_19113_M_Accepted_08/28/2018 14


Foot Care (podiatry services) YOU PAY $50 copayment per visit Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions.

Durable Medical Equipment1 YOU PAY 20% of the total cost Includes wheelchairs, oxygen, etc.

Cardiac Rehabilitation YOU PAY $0 copayment per visit Cardiac and Pulmonary rehabilitation visits.

Chiropractic Care YOU PAY $20 copayment per visit Medicare-covered services only.

Diabetes Supplies and Services●Diabetes monitoring supplies from

Retail Pharmacy

●Diabetes monitoring supplies fromDME supplier

●Diabetes self-management training

●Therapeutic shoes or inserts





Dialysis YOU PAY 20% of the total cost


Prosthetic devices 1 YOU PAY 20% of the total cost Braces, artificial limbs, etc.

Fitness Center Membership YOU PAY $10 copayment per month Applies to fitness membership at any FirstHealth Center for Health and Fitness. A member may use another plan approved fitness center and be reimbursed up to $180 annually for fees. Reimbursements are made on a quarterly basis and will not be paid in advance.

H6306_19113_M_Accepted_08/28/2018 15


Part D Deductible YOU PAY $300 annually Tier 1 and Tier 6 do not apply to the deductible.




Tier 3 (Preferred Brand Drugs) YOU PAY $45 copayment YOU PAY $45 copayment


Tier 5 (Specialty Drugs) YOU PAY 25% of the total cost YOU PAY 25% of the total cost




Tier 3 (Preferred Brand Drugs) YOU PAY $135 copayment YOU PAY $112.50 copayment


Tier 5 (Specialty Drugs) A long term supply is not available in Tier 5.



PRESCRIPTION DRUGS





H6306_19113_M_Accepted_08/28/2018 16






17H6306_19113_M_Accepted_08/28/2018

18

PREMIUM and BENEFITS IN NETWORK OUT-OF-NETWORK WHAT YOU SHOULD KNOWMonthly Plan Premium You must continue to pay your

Medicare Part B premium.

Part C Deductible This plan does not have a medical deductible.

Maximum Out of Pocket $5,000 In-Network annually

$10,000 combined In and Out-of-Network annually

The most you pay for copayments, coinsurance, and other costs of medical services for the year.

Inpatient Hospital Care1 YOU PAY $295 copayment per day for days 1-6


YOU PAY 20% of the total cost per stay

The copayments for hospital benefits are based on benefit periods as defined by Medicare.

Outpatient Hospital Care●Outpatient Surgery or

Ambulatory Surgery Services

●Other OutpatientServices








Includes outpatient hospital or ambulatory surgery services. One copayment applies for bilateral cataract surgery if both performed in the same calendar year.


●Specialist





FirstMedicare Direct PPO Plus (PPO)

YOU PAY $73

YOU PAY nothing

●SERVICES WITH A1 MAY REQUIRE PRIOR AUTHORIZATION●

H8064_19112_M_Accepted 08/28/2018 19

PREMIUM and BENEFITS IN NETWORK OUT-OF-NETWORK WHAT YOU SHOULD KNOW




Includes but not limited to Medicare-covered: glaucoma screening, diabetes self- management training, barium enemas, digital rectal exams, and EKG following Welcome Visit.

Emergency Care ER Copayment is waived if admitted within 48 hours.

Worldwide Emergency Coverage

Copayment is NOT waived for worldwide services.

$10,000 lifetime limit for worldwide emergency coverage outside of the United States.

Urgently Needed Services Copayment is NOT waived if you are admitted to the hospital.

Diagnostic Tests, Lab, Therapeutic Radiology

Services and X-rays1



Such as MRIs, CT scans, outpatient x-rays.

Hearing Services YOU PAY $50 copayment per visit


Medicare Covered exams to diagnose and treat hearing and balance issues.

Dental Services YOU PAY $50 copayment per visit


Medicare Covered dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth).







H8064_19112_M_Accepted 08/28/2018 20



Vision Services●Medicare Covered

Eye Exam

●Medicare CoveredAnnual Glaucoma Test

●Post CataractSurgery Eyewear

●Routine Eye Exam









Services to diagnose and treat diseases and conditions of the eye.


Outpatient Mental Health Services



Group or individual therapy visits.




The copayments for hospital benefits are based on benefit periods as defined by Medicare. Covers up to 190 days in a lifetime in a psychiatric hospital.This limit does not apply to inpatient mental services provided in a general hospital.





H8064_19112_M_Accepted 08/28/2018 21



Outpatient Rehabilitation Services



Occupational, physical, speech and language therapies.

Ambulance1


●Air TransportationService

Authorization required for non- emergency services.

Medically necessary Medicare- covered ground or air medical transportation.

Transportation Non-medical transportation is not a covered service.

Medicare Part B Drugs1 Part B Chemotherapy and other Medicare Part B covered drugs.

Foot Care (podiatry services) YOU PAY $50 copayment per visit


Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions.

Durable Medical Equipment1 YOU PAY 20% of the total cost


Includes wheelchairs, oxygen, etc.

Cardiac Rehabilitation YOU PAY $0 copayment per visit


Cardiac and Pulmonary rehabilitation visits.

Chiropractic Care YOU PAY $20 copayment per visit


Medicare-covered services only.




NOT COVERED

H8064_19112_M_Accepted 08/28/2018 22



Diabetes Supplies and Services●Diabetes monitoring

supplies from Retail Pharmacy

●Diabetes monitoringsupplies from DMEsupplier

●Diabetes self- management

training

●Therapeutic shoesor inserts









Dialysis YOU PAY 20% of the total cost for each Medicare-covered dialysis service.

YOU PAY 20% of the total cost for each Medicare-covered dialysis service.



Prosthetic devices 1 YOU PAY 20% of the total cost


Braces, artificial limbs, etc.

Fitness Center Membership Applies to fitness membership at any FirstHealth Center for Health and Fitness. A member may use another plan approved fitness center and be reimbursed up to $300 annually for fees. Reimbursements are made on a quarterly basis and will not be paid in advance.

YOU PAY $0

H8064_19112_M_Accepted 08/28/2018 23



Part D Deductible This plan does not have a Part D deductible.


Tier 1 (Preferred Generic Drugs)

YOU PAY $8 copayment YOU PAY $8 copayment


Tier 3 (Preferred Brand Drugs)


Tier 4 (Non-Preferred Drugs) YOU PAY $100 copayment

YOU PAY $100 copayment

Tier 5 (Specialty Drugs) YOU PAY 33% of the total cost



Tier 1 (Preferred Generic Drugs)



Tier 3 (Preferred Brand Drugs)


YOU PAY $112.50 copayment

Tier 4 (Non-Preferred Drugs) YOU PAY $300 copayment


Tier 5 (Specialty Drugs) A long term supply is not available in Tier 5.





YOU PAY nothing

PRESCRIPTION DRUGS



H8064_19112_M_Accepted 08/28/2018 24

Out-of-network/non-contracted providers are under no obligation to treat FirstMedicare Direct H8064-002 members, except in emergency situations. Please call our member services number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.






25H8064_19112_M_Accepted 08/28/2018

All FirstMedicare Direct members have access to the Nurse Advice Line to get health care information 24 hours a day, 7 days a week. Specially trained nurses help you when you have questions about health concerns or need health information.

The Nurse Advice Line is available at no cost at 1- 866-902-7477.

The Nurse Advice Line can help you decide what kind of care to seek. You might be able to treat the condition at home, you might need to see your doctor, or you might need to get urgent or immediate care.

When you enroll, the toll free Nurse Advice Line will be on the back of your FirstMedicare Direct identification card.

Just another way we care about your health.

NURSE ADVICE LINE

26

Y0094_19050_C

Pre-Enrollment Checklist

Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at 877-279-1732

Understanding the Benefits

Review the full list of benefits found in the Evidence of Coverage (EOC), especiallyfor those services that you routinely see a doctor. Visit www.FirstMedicare.com orcall 877-279-1732 to view a copy of the EOC.

Review the provider directory (or ask your doctor) to make sure the doctors you seenow are in the network. If they are not listed, it means you will likely have to selecta new doctor.

Review the pharmacy directory to make sure the pharmacy you use for anyprescription medicines is in the network. If the pharmacy is not listed, you will likelyhave to select a new pharmacy for your prescriptions.

Understanding Important Rules

In addition to your monthly plan premium, you must continue to pay your MedicarePart B premium. This premium is normally taken out of your Social Security checkeach month.

Benefits, premiums and/or copayments/co-insurance may change on January 1,2019.

HMO Applicants: Except in emergency or urgent situations, we do not cover servicesby out-of-network providers (doctors who are not listed in the provider directory).

PPO Applicants: Our plan allows you to see providers outside of our network (non-contracted providers). However, while we will pay for covered services providedby a non-contracted provider, the provider must agree to treat you. Except in anemergency or urgent situations, non-contracted providers may deny care. Inaddition, you will pay a higher co-pay for services received by non-contractedproviders.

I have read the above checklist and wish to proceed

FirstCarolinaCare Insurance Company's FirstMedicare Direct plans are HMO and PPO plans with a Medicare contract. Enrollment in a FirstMedicare Direct plan depends on contract renewal.

27

Y0094_19301_M_Accepted_08/14/18

Hours of Operation: Our Member Services number is 1-844-201-4957 TTY: 711, 8:00 a.m. to 8:00 p.m. Eastern, 7 days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday through Friday (except holidays) from April 1 through September 30. Disclaimers: FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO health plans with Medicare contracts. Enrollment in FirstMedicare Direct depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B premium. Out-of-network/non-contracted providers are under no obligation to treat members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our Member Services number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. FirstCarolinaCare Insurance Company complies with federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATTENTION: If you speak a language other than English, assistance services, free of charge, are available to you. Call 1-844-201-4957 (TTY 711). Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-844-201-4957 (TTY 711). 繁體中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-844-201-4957（TTY 711)。

28

Enrollment Quick Reference Guide To start your enrollment application, you will need:

1. Your Medicare card - the application requires you to enter your Medicare number and yourPart A and Part B effective dates

2. Your list of medications - so you can check the drug lookup tool to make sure your medications are covered by us

3. Your primary care physician's name - so you can check to make sure your primary care physicianparticipates in our plans

How to enroll:

To enroll by phone - call toll-free at 1-877-279-1732. Hearing impaired persons call TTY 711. Our call hours are 8:00 a.m. to 8:00 p.m. EST, 7 days a week from October 1 – March 31, and from 8:00 a.m. to 8:00 p.m. EST, Monday-Friday, from April 1 - September 30.

By mail - send the completed enrollment form to:

FirstMedicare Direct 42 Memorial Drive Pinehurst, NC 28374

Online - go to www.FirstMedicare.com and click on CHOOSE YOUR COUNTY (GO) ENROLL NOW

Note: Medicare beneficiaries may also enroll in FirstMedicare Direct plans through the CMS Medicare Online Enrollment Center located at https:/www.medicare.gov.

29

NETWORK PRIMARY CARE PROVIDERS

The next pages are a partial listing of Primary Care Providers (PCPs) in the FirstMedicare Direct network in the following counties: CHATHAM, HOKE, LEE, MOORE, MONTGOMERY, RICHMOND AND SCOTLAND. This list is accurate as of the time of printing. The provider network may change at any time. You will receive notice when necessary. Other Providers are available in our network.

To access a searchable ONLINE Provider Directory follow the directions below:

1. Visit www.FirstMedicare.com.2. Choose Your County from drop down menu/click Go.3. Choose Members at top of next page.4. On the left hand side of the page choose Find a Provider.5. Under Type of Coverage choose FirstMedicare Direct.

You may search for network providers by name, location and specialty.

For a complete listing, you may request a print Provider Directory or if you need help finding a Network Provider please call Member Services:

1-844-201-4957

We are available for phone calls from 8 am- 8 pm Eastern, 7 days a week between October 1 and March 31, and from 8 am-8 pm Eastern, Monday- Friday, between April 1 and September 30.

You may also request a Provider Directory be mailed to your home by following the directions below.

1. Visit www.FirstMedicare.com.2. Choose Your County from drop down menu/click Go.3. Choose Members at top of next page.4. On the left hand side of the page choose Find a Provider.5. On the next page it states: “If you would like to request a print Provider

Directory, compete the form here.”6. Fill out your name and address. Choose SUBMIT.

30

Y0094_19028_C

EVIDENCE OF COVERAGE, PROVIDER AND PHARMACY DIRECTORIES AND FORMULARY/DRUG WEB LOOK UP

FirstMedicare Direct is going Green!

Help us reduce paper usage by searching for your 2019 Evidence of Coverage (EOC), network Providers, Pharmacies, or for your Formulary (a list of covered drugs) through our website. When you visit www.FirstMedicare.com, you have access to a complete listing of FirstMedicare Direct Providers and Pharmacies, as well as a complete list of covered drugs, and a search tool you can use to find your drug on our formulary list. Starting October 15, 2018, you will also have access to your plan’s Evidence of Coverage on our website.

How do I locate these documents? 1. Go to our FirstMedicare Direct website at: www.FirstMedicare.com2. Choose “Your County” (e.g. Buncombe, Moore, Wake, etc.)3. Select the “Members” tab

a.) For the Evidence of Coverage, choose “Coverage Documents” and click on the 2019 Evidence of Coverage for your plan.

b.) For a Provider Directory, choose “Find a Provider” to view a full directory of providers in your area.

c.) For a Pharmacy Directory, choose “Pharmacy Corner” and select “Pharmacy Directory and Locator” link to view a complete directory, or use our search tool to find your pharmacy.

d.) To view the Formulary, choose “Pharmacy Corner”, select the “Covered Drugs” link and choose the Formulary for your Plan to view a full Formulary, or use our search tool to search for your drugs.

What if I need help or would like to receive a printed copy of any of these documents? If you need help with these tools, or need help finding a network provider and/or pharmacy, or if you have a question about covered drugs, please call 1-844-201-4957 or visit www.FirstMedicare.com to access our online searchable directories. If you would like an Evidence of Coverage, Provider/Pharmacy Directory or a Formulary mailed to you, you may call the number above, or request one at the website link provided above. Calls to our Member Services line are free. We are available for phone calls 8:00 a.m.-8:00 p.m. Eastern from October 1- March 31, 7 days a week, and from April 1- September 30, Monday through Friday. Member Services also has free language interpreter services available for non-English speakers. FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO health plans with Medicare contracts. Enrollment in a FirstMedicare Direct plan depends upon contract renewal. FirstCarolinaCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Pharmacy network and/or provider network may change at any time. You will receive notice when necessary.

31

County Provider SpecialtyChathamChatham Ajmani, Ajay K, MD Internal MedicineChatham Angle, Lucy M, PA-C Family MedicineChatham Asher, Gary N, MD Family MedicineChatham Barzin, Amir H, DO Family MedicineChatham Boyd, William S, PAC Family MedicineChatham Buebel, Michael S, MD Family MedicineChatham Burgert, Woodward , MD Family MedicineChatham Butler, Erik S, DO Family MedicineChatham Cates, Daphne J, MD Family MedicineChatham Chelminski, Paul R, MD Internal Medicine *Chatham Cirigliano, Mary K, DO Family MedicineChatham Clark, Candice P, FNP Family MedicineChatham Collins, Ann Marie , PA Family MedicineChatham Corey, John D, MD Family MedicineChatham Crites, Savannah N, MD Family MedicineChatham Davis, Debra L, FNP Family MedicineChatham Davis, James Wayne , MD Family MedicineChatham Desmond, Elizabeth S, PA-C Family MedicineChatham Dodson, Hannah J, FNP Family MedicineChatham Dolleschel, Emily K, NP Family MedicineChatham Driggers, Laura A, PA-C Family MedicineChatham Drostin, Christina M, MD Family MedicineChatham East, Joan , MD Family MedicineChatham Feller, Cathy M, MD Family MedicineChatham Flanagan, Angelia M, MD Family MedicineChatham Freuler, Aaron T, PAC Family MedicineChatham Fuhr, Hannah , MD Family MedicineChatham Garlick, William L, MD Family MedicineChatham Gay, Laura C, MD Family MedicineChatham Gibson, David Ellis, MD Family MedicineChatham Gilmer-Scott, Melissa D, MD Family MedicineChatham Gruber, Leah M, PA Family MedicineChatham Gwynne, Mark D, DO Family MedicineChatham Halpert, Karen D, MD Family MedicineChatham Hannapel, Andrew C, MD Family MedicineChatham Hargett, Franklin , MD Family Medicine

FirstMedicare Direct Primary Care Providers (PCPs)

*Currently NOT accepting new Medicare, Medicaid or other new patients.

32

County Provider Specialty


Chatham Hester, Laura A, MD Family MedicineChatham Hobbs, Phillip M, MD Family MedicineChatham Hoffman, Bryon J, MD Internal MedicineChatham Holmes, Mary T, NP Family MedicineChatham Holt, James B, MD Family/Geriatric

MedicineChatham House, Laura K, MD Family MedicineChatham Julich, Cynthia C, FNP Family MedicineChatham Kathard, Haresh M, MD Family MedicineChatham Kooistra, Rebecca A, FNP Family MedicineChatham Koonce, Thomas F, MD Family MedicineChatham Lam, Yee , MD Family MedicineChatham McEachern, Morgan A, MD Family MedicineChatham McLester Brown, Mallory , MD Family MedicineChatham Miles, Mimi , MD Family MedicineChatham Mounsey, Anne L, MD Family MedicineChatham Neutze, Dana M, MD Family MedicineChatham Oettinger, Matthew D, MD Family MedicineChatham Ortiz Pate, Nathalie , PA-C Family MedicineChatham Pettigrew, Erica M, MD Family MedicineChatham Phung, Andy , DO Family MedicineChatham Porras, Laureen P, MD Internal MedicineChatham Powell, Ronald J, MD Urgent Care

MedicineChatham Putnam, Marshall E, PA-C Urgent Care

MedicineChatham Reddy, Vinay C, MD Family MedicineChatham Roberts, Caroline C, MD Family MedicineChatham Sargent, Julia M, DO Family MedicineChatham Scott, Jewel L, FNP Family MedicineChatham Shah, Uma U, MD Family Medicine *Chatham Sloane, Philip D, MD Family MedicineChatham Smith, Donna C, FNP Family MedicineChatham Spach, Brenda L, FNP Geriatric MedicineChatham Weiland, Paul J, MD Family MedicineChatham Willett, Annette C, FNP Family MedicineChatham Williams, Kia J, MD Family Medicine


33



Chatham Wilson, Amelia P, MD Family MedicineHokeHoke Allred, Jolena B, FNP Family MedicineHoke Barber Jr., Alvin F, MPAC Family MedicineHoke Bass, Diedre M, PAC Family MedicineHoke Bedini, Tabitha M, MD Family MedicineHoke Blackmon, Katherine T, FNP Urgent Care

MedicineHoke Bradley, Betty Lou B, MD Family MedicineHoke Brown, Allen , PA Family MedicineHoke Castillo-Powell, Maria C, MPAC Family MedicineHoke Collins, Nathaniel D, FNP-BC, COHC Family MedicineHoke Cuza, William , FNP Family MedicineHoke Dorsey, Gladys N, FNP Family MedicineHoke Farmer, Vickie L, PA-C Family MedicineHoke Gaweda, Amy G, FNP Family MedicineHoke Gehan, Kara L, MPAC Family MedicineHoke Greene, Kate Elaine, PAC Family MedicineHoke Harley, Lisa Tamara, PAC Family MedicineHoke Hoover, Sara K, MPAC Family MedicineHoke Hughes, Linda K, MD Family MedicineHoke Hurley, Patrick Scott, MPAC Urgent Care

MedicineHoke Jones, Shaquita D, FNP Family MedicineHoke Kapa, Stephen S, MPAC Family MedicineHoke Kobaissi, Zena A, MPAC Family MedicineHoke Kohl, Meghan A, FNP Family MedicineHoke Liffrig, James R, MD Family MedicineHoke Lowry, Garnett Marcus, MD Family MedicineHoke Lucarelli, Christine Monique, MD Internal MedicineHoke Martin, Laura G, MPAC Family MedicineHoke McNeill, Amanda C, PA-C Family MedicineHoke Morris, Deborah L, MD Urgent Care

MedicineHoke Newell, Mary Kathryn, PAC Family MedicineHoke Nicholson, Todd R, PAC Family MedicineHoke Nissen, Michael D, FNP Family Medicine


34



Hoke Reich, Tricia L, FNP Family MedicineHoke Richards, Ann Marie T, MD Family MedicineHoke Ross, Kristen Elise, MPAC Family MedicineHoke Smith, Karen L, MD Family MedicineHoke Taylor, James B, PA Family MedicineHoke Thomas, Julie M, MPAC Internal MedicineHoke Townsend III, Robert G, DO Family MedicineHoke Wilkins, Thomas L, MPAC Family MedicineHoke Wills, Leah M, MPAC Family MedicineLeeLee Ajmani, Ajay K, MD Internal MedicineLee Aubin, Melissa Sue, MPAC Family MedicineLee Barber Jr., Alvin F, MPAC Family MedicineLee Baxley, Laura A, FNP Family MedicineLee Bunao, Alfred S, MD Family MedicineLee Burgert, Jessica W, MD Family MedicineLee Butler, Erik S, DO Family MedicineLee Caldwell, Andrew C, DO Family MedicineLee Cates, Daphne J, MD Family MedicineLee Chapin, Sally J, FNP Family MedicineLee Collins, Nathaniel D, FNP-BC, COHC Family MedicineLee Condit, Bridget F, Anp Family MedicineLee Finlay-Tozzi, Kim A, DO Internal MedicineLee Garrett, Dana L, MD Family MedicineLee Gehan, Kara L, MPAC Family MedicineLee Greene, Kate Elaine, PAC Family MedicineLee Grider, Glenna L, MD Internal Medicine *Lee Gruber, Leah M, PA Family MedicineLee Hargett, Franklin , MD Family MedicineLee Harley, Lisa Tamara, PAC Family MedicineLee Holt, James B, MD Family/Geriatric

MedicineLee Julich, Cynthia C, FNP Family MedicineLee Lambert, Jill J, MD Family MedicineLee Liffrig, James R, MD Family MedicineLee Lucarelli, Christine Monique, MD Internal MedicineLee Mangum, John R, MD Family Medicine *


35



Lee McConville, Parker S, MD Family MedicineLee McConville, Robert H, MD Family MedicineLee Nadkarni, Vaishali R, MD Family Medicine *Lee Nave Jr, Lester D, MD Family Medicine *Lee Normann, Jennifer B, MD Internal Medicine *Lee O'Donnell, Gerard J, MD Internal MedicineLee Peck, June L, FNP Family MedicineLee Pisharody, Murali D, MD Family MedicineLee Pokroy, Denise , FNP Family MedicineLee Powell, Ronald J, MD Urgent Care

MedicineLee Putnam, Marshall E, PA-C Urgent Care

MedicineLee Richards, Ann Marie T, MD Family MedicineLee Ross, Kristen Elise, MPAC Family MedicineLee Shah, Uma U, MD Family MedicineLee Stanfield, Beth P, FNP Family Medicine *Lee Trujillo, Cheyanna Lynn, FNP Family MedicineLee Weiland, Paul J, MD Family MedicineLee Wills, Leah M, MPAC Family MedicineMontgomeryMontgomery Barnes, Daniel R, DO Internal MedicineMontgomery Blackmon, Katherine T, FNP Urgent Care

MedicineMontgomery Bradley, Betty Lou B, MD Family Medicine *Montgomery Britt, Janet Leone, PAC Family MedicineMontgomery Bryan, Taressa Aliene, FNP Family MedicineMontgomery Coggins, Julie Taylor, FNP-C Family MedicineMontgomery Eller, Chrystal F, MD Family MedicineMontgomery Fretwell, Cherise M, CNM Family MedicineMontgomery Hibbard, James Mitchell, MPAC Family MedicineMontgomery Hoover, Sara K, MPAC Family MedicineMontgomery Kopynec, Bohdan W, MD Family MedicineMontgomery Latva, Donna M, NP Family MedicineMontgomery Matthews, Daniel A, MPAC Family MedicineMontgomery McBride, Christine A, MPAC Family MedicineMontgomery McGee, Cassie N, PA-C Family Medicine


36



Montgomery Nor, Eugene B, MD Family MedicineMontgomery Richards, Ann Marie T, MD Family MedicineMontgomery Vang, Touber , MD Family MedicineMontgomery Woodyear Jr, John M, MD Family MedicineMooreMoore Allred, Jolena B, FNP Family MedicineMoore Antil, Michael A, MD Internal MedicineMoore Ballard, Marcia H, FNP Family MedicineMoore Barber Jr., Alvin F, MPAC Family MedicineMoore Bass, Diedre M, PAC Family MedicineMoore Bateman, Debra L, FNP Family MedicineMoore Baugher, Julie G, MD Internal MedicineMoore Bell, William L, MD Family MedicineMoore Blackmon, Katherine T, FNP Urgent Care

MedicineMoore Blakely, Greg M, MD Internal MedicineMoore Brackman, Marri K, DO Family MedicineMoore Brackman, Michael R, DO Family Medicine *Moore Castillo-Powell, Maria C, MPAC Family MedicineMoore Chamlee, Gina Satterfield, FNP Family MedicineMoore Chriscoe, Lauren B, ANP Internal MedicineMoore Christaldi, Pamela Sue , ANP Internal MedicineMoore Collins Jr, Francis Farrell, MD Internal MedicineMoore Collins, Nathaniel D, FNP-BC, COHC Family MedicineMoore Crozier, Casey A, FNP Family MedicineMoore Cuza, William , FNP Family MedicineMoore Daley, Michael B, MD Internal Medicine *Moore Deucher, Robert L, MD Internal MedicineMoore Dyer, Heather , NP Family MedicineMoore Eller, Chrystal F, MD Family MedicineMoore Evans, Brianne H, PAC Family MedicineMoore Faulk, Shawana A, FNP Family MedicineMoore Gast, Timothy M, PAC Family MedicineMoore Gehan, Kara L, MPAC Family MedicineMoore Greene, Kate Elaine, PAC Family MedicineMoore Harley, Lisa Tamara, PAC Family MedicineMoore Hipp, David E, MD Internal Medicine *


37



Moore Hoover, Sara K, MPAC Family MedicineMoore Hounsell, Angie F, FNP Internal MedicineMoore Jameson III, John W, MD Family Medicine *Moore Kapa, Stephen S, MPAC Family MedicineMoore Kern, Jeffrey J, MPAC Family MedicineMoore Kersbergen, David J, DO Family MedicineMoore Kirchner, Kathy L, ANP Internal MedicineMoore Lam, Douglas E, MD Family Medicine *Moore Leonard, Thomas R, MD Family MedicineMoore Letizia, Kathleen A, MD Internal MedicineMoore Liffrig, James R, MD Family MedicineMoore Lineberger, Thomas H, MD Internal Medicine *Moore Lowry, Garnett Marcus, MD Family MedicineMoore Lucarelli, Christine Monique, MD Internal MedicineMoore Marcum, Stacy L, PA-C Internal MedicineMoore Martin, Amanda H, ANP Family MedicineMoore Martin, Laura G, MPAC Family MedicineMoore Maynor Jr, Bobby R, MD Internal MedicineMoore McAdoo, Tracy C, FNP Family MedicineMoore McGee, Cassie N, PA-C Family MedicineMoore Mercier, Randall Robert, MD Internal MedicineMoore Mills, Deanna L, ANP Internal MedicineMoore Monroe, Margaret A, FNP Family MedicineMoore Morris III, Walter S, MD Internal MedicineMoore Murphy, Leslie C, MD Internal MedicineMoore Murphy, LuAnne C, FNP Internal MedicineMoore Nicholson, Todd R, PAC Family MedicineMoore Nickel, Marshall S, MD Family MedicineMoore Norris, Bobbie E, NP Internal MedicineMoore Phillips, Tracey B, FNP Family MedicineMoore Prussian, Kathleen H, FNP Family MedicineMoore Purvis, Leslie C, FNP Family MedicineMoore Reives, Vonda H, FNP Family MedicineMoore Richards, Ann Marie T, MD Family MedicineMoore Richards, Ann T, MD Family MedicineMoore Rodriguez, Fabian D, MD Internal MedicineMoore Ross, Kristen Elise, MPAC Family Medicine


38



Moore Sharrer, Julie M, PA-C Internal MedicineMoore Short, Jeffery P, PAC Family MedicineMoore Sinclair, Jessica L, PA-C Family MedicineMoore Stanzione, Michol , DO Internal MedicineMoore Szurgot, Jennifer G, MD Internal Medicine *Moore Taylor-Miller, Bertha , FNP Family MedicineMoore Thomas, Julie M MPAC Internal Medicine *Moore Ung, Padiwath C, MD Internal MedicineMoore Walters, Ronald D, MD Internal MedicineMoore Wilkins, Thomas L, MPAC Family MedicineMoore Williamson, Sondra N, ANP Internal Medicine *Moore Wills, Leah M, MPAC Family MedicineMoore Wolf, Harvey H, MD Internal MedicineMoore Woodyear Jr, John M, MD Family MedicineMoore Young, Alysa D, FNP Family MedicineRichmondRichmond Barber Jr., Alvin F, MPAC Family MedicineRichmond Bass, Diedre M, PAC Family MedicineRichmond Blackmon, Katherine T, FNP Urgent Care

MedicineRichmond Bowman, Melva R, MD Family MedicineRichmond Brown, Diane L, ANP Family MedicineRichmond Burgess, Kathy H, FNP Family MedicineRichmond Castillo-Powell, Maria C, MPAC Family MedicineRichmond Coggins, Julie Taylor , FNP-C Family MedicineRichmond Collins, Nathaniel D, FNP-BC, COHC Family MedicineRichmond Cuza, William , FNP Family MedicineRichmond Emmons, David H, FNP Family MedicineRichmond Flannery, John E, MD Internal MedicineRichmond Gillham, Joseph E, MD Family MedicineRichmond Greene, Kate Elaine, PAC Family MedicineRichmond Hall, Daniel C, MD Family MedicineRichmond Harley, Lisa Tamara, PAC Family MedicineRichmond Hoover, Sara K, MPAC Family MedicineRichmond Kapa, Stephen S, MPAC Family MedicineRichmond Kern, Jeffrey J, MPAC Family MedicineRichmond Kopynec, Bohdan W, MD Family Medicine


39



Richmond Liffrig, James R, MD Family MedicineRichmond Lobaina, Gleybis Sanchez, MD Internal MedicineRichmond Lowry, Garnett Marcus, MD Family MedicineRichmond Mangrum, Charlita R, MD Family MedicineRichmond McBride, Christine A, MPAC Family MedicineRichmond McLemore, Cynthia W, MD General MedicineRichmond McQueen Jr, Fred D, MD Family MedicineRichmond Millen, Steven D, ANP Family MedicineRichmond Morgan, Erin Elizabeth, PAC Family MedicineRichmond Nascimento, Luiz , MD Internal MedicineRichmond Nicholson, Todd R, PAC Family MedicineRichmond Patel, Shilpesh P, MD Internal MedicineRichmond Phillips, Emily N, MPAC Internal MedicineRichmond Richards, Ann Marie T, MD Family MedicineRichmond Ross, Kristen Elise, MPAC Family MedicineRichmond Sanford, Janet L, FNP Family MedicineRichmond Thomas, Julie M, MPAC Internal MedicineRichmond Thompson, Bridget N, MPAC Family MedicineRichmond Webb, Patsy C, NP Family MedicineRichmond Wilkins, Thomas L, MPAC Family MedicineRichmond Wills, Leah M, MPAC Family MedicineRichmond Young-Cadore, Dierdre T, MD Internal MedicineScotlandScotland Armwood, Kelli O, NP Geriatric MedicineScotland Ball Jr, Frank J, MD Internal Medicine *Scotland Ballew, Allen J, DO Family MedicineScotland Bates, Jaclyn W, PA-C Family MedicineScotland Beane, Alice D, FNP Family MedicineScotland Bhiro, Dixie L, PA Family MedicineScotland Bhiro, Thakurdeo M, PA Family MedicineScotland Blackmon, Katherine T, FNP Urgent Care

MedicineScotland Bracey, Lisa E, MD Family MedicineScotland Copeland, Tabitha L, WHNP Family MedicineScotland Couch, Philip R, FNP Family MedicineScotland Cowan, Terri B, PA-C Family MedicineScotland Cox, James M, PA Family Medicine


40



Scotland Eteo, Tonya E, FNP Family MedicineScotland Faulkenberry, Bradford K, MD Family MedicineScotland Forgach, Mary R, PA-C Urgent Care

MedicineScotland Freeman, Ashleigh J, MD Family MedicineScotland Gainey, Sarah D, PA Urgent Care

MedicineScotland Gibson, Donna E, FNP Family MedicineScotland Harris, Glenn R, MD Family MedicineScotland Howell, David A, MD Family MedicineScotland Hurley, Patrick Scott, MPAC Urgent Care

MedicineScotland Iqbal, Muhammad Jawad, MD Internal MedicineScotland Jackson, Charles Edward, FNP Family MedicineScotland Locklear, Ashley M, PA Family MedicineScotland Lucarelli, Christine Monique, MD Internal MedicineScotland Manzo, Matthew T, DO Family MedicineScotland Monroe, Margaret A, FNP Family MedicineScotland Moree, Mary C, MD Family MedicineScotland Murphy, LuAnne C, FNP Internal MedicineScotland Murphy, Moneika O, MD Family MedicineScotland Neal, John W, MD Family MedicineScotland Newton, Mary A, FNP Family MedicineScotland Nor, Eugene B, MD Family MedicineScotland Notaro, Mary C, DO Family MedicineScotland Oxendine, Leslie K, FNP Family MedicineScotland Oxendine, Toni C, MD Internal MedicineScotland Reese, Lindsay E, PA-C Family MedicineScotland Rockwiley, Keith S, PA-C Urgent Care

MedicineScotland Rowson, Jonathan D, MD Family MedicineScotland Sciarra, Marc A, DO Family MedicineScotland Sozzi, Shannon J, NP Family MedicineScotland Thomas, Carrie H, PA-C Family MedicineScotland Tunau, Habiba , MD Internal MedicineScotland Ventrilla, James J, PA Family MedicineScotland Wolonick, Richard C, DO Family Medicine


41

Y0094_19027_C

Discrimination is Against the Law

FirstCarolinaCare Insurance Company complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. FirstCarolinaCare Insurance Company does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

FirstCarolinaCare Insurance Company provides free aids and services to people withdisabilities to communicate effectively with us, such as:

○ Qualified sign language interpreters

○ Written information in other formats (large print, audio, accessible electronic formats,other formats).

Provides free language services to people whose primary language is not English, such as:○ Qualified interpreters

○ Information written in other languages.

If you need these services, contact the Civil Rights Coordinator for FirstCarolinaCare Insurance Company. If you believe that FirstCarolinaCare Insurance Company has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

FCC Civil Rights Coordinator FirstCarolinaCare Insurance Company 42 Memorial Drive Pinehurst, NC 28374 Telephone: 910-715-8114 Fax number: 910-715-8101 Email: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the FCC Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHS Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

42

Y0094_19027_C

MULTI-LANGUAGE INTERPRETER SERVICES

Español (Spanish)

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

Llame al 1-844-201-4957 (TTY 711).

繁體中文 (Chinese)

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-844-201-4957（TTY

711)。

Tiếng Việt (Vietnamese)

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-

844-201-4957 (TTY 711).

한국어 (Korean)

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-844-

201-4957 (TTY 711)번으로 전화해 주십시오.

Français (French)

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés

gratuitement. Appelez le 1-844-201-4957 (ATS 711).

ة (Arabic) العربي

-4957-201-844<<- 1ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم

-TTY 711(رقم ھاتف الصم والبكم:

43

Y0094_19027_C

Hmoob (Hmong)

LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu

rau 1-844-201-4957 (TTY 711).

Русский (Russian)

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-844-201-4957 (телетайп: 711).

Tagalog (Tagalog – Filipino)

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa

wika nang walang bayad. Tumawag sa 1-844-201-4957 (TTY 711).

જુરાતી (Gujarati)

ચુના: જો તમે જુરાતી બોલતા હો, તો િન: ુ ક ભાષા સહાય સેવાઓ તમારા માટ ઉપલ ધ છે. ફોન કરો1-844-201-4957 (TTY 711). ែខមរ (Cambodian)

របយ័តន៖ េបើសិនជាអនកនិយាយ ភាសាែខមរ, េសវាជំនួយែផនកភាសា េដាយមិនគិតឈនួល គឺអាចមានសំរាប់បំេរីអនក។ ចូរ ទូរស័ពទ 1-844-201-4957 (TTY 711)។

Deutsch (German)

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen

zur Verfügung. Rufnummer: 1-844-201-4957 (TTY 711).

िहंदी (Hindi)

यान द: यिद आप िहदंी बोलत ेह तो आपके िलए मु त म भाषा सहायता सेवाए ंउपल ध ह। 1-844-201-4957 (TTY 711) पर कॉल कर।

ພາສາລາວ (Lao)

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ ້ າພາສາ ລາວ, ການບໍ ລິ ການຊ່ວຍເຫຼື ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ, ແມ່ນມີ

ພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-844-201-4957 (TTY 711).

日本語 (Japanese)

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-844-201-

4957（TTY:711）まで、お電話にてご連絡ください。

44

FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO plans with a Medicare contract. Enrollment in a FirstMedicare Direct plan depends on contract renewal.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments and restrictions may apply. Benefits may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

Y0094_19221_M_Approved_09/18/2018

45