smartHMO ENROLLMENT BOOK a Plan/Documents/2020...ENROLLMENT BOOK H6306_20007_C 1 WELCOME FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO health plans

W A K E C O U N T YsmartHMO

FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO health plans with Medicare contracts. Enrollment in FirstMedicare Direct depends on 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.

www.FirstMedicare.com(855) 903-5154 • TTY USERS CALL 7118:00 a.m. to 8:00 p.m. Eastern, 7 days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

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H6306_20007_C

1

WELCOME

FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO health plans with Medicare contracts. Enrollment in FirstMedicare Direct depends on contract renewal. First CarolinaCare 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. ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 844-499-5630 (TTY 711).

Dear Medicare Beneficiary:

Enclosed is information about FirstMedicare Direct smartHMO 005.

The information in this booklet will help you explore the benefits of becoming a member. We encourage you to review the enclosed Summaries of Benefits as it provides detailed information about benefits that the plan offers. If you have questions about anything in this booklet, please do not hesitate to call us at the numbers listed in this booklet.

If you decide to enroll, we have enclosed an enrollment form and a postage paid envelope so you can return your completed enrollment form. Please note that you may enroll in the plan only during specific times of the year, which is explained on the enrollment form. Benefits and cost sharing may change from year to year.

If you choose to enroll, you will receive a confirmation of enrollment letter, followed by your New Member Welcome Kit, including the Evidence of Coverage, and information about how to access our Prescription Drug Formulary, Provider and Pharmacy Directories. Before your effective date, you will receive your ID card.

Thank you for your interest in FirstMedicare Direct and we look forward to the opportunity to serve you.

Sincerely,

F. Craig Humphrey President, FirstCarolinaCare Insurance Company

3

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.

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

• Qualified sign language interpreters

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

w 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: 855-367-8184 Fax number: 910-235-7854 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.

DISCRIMINATION IS AGAINST THE LAW

Y0094_20006_C_FMD Approved_08/14/2019

4

MULTI-LANGUAGE INTERPRETER SERVICES

Y0094_20007_C_FMD Approved_08/14/2019

Y0094_20007_C_FMDApproved_08/14/2019

MULTI-LANGUAGE INTERPRETER SERVICESEspañol (Spanish)

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

lingüística. Llame al 1-844-499-5630 (TTY 711).

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7

TABLE OF CONTENTS

Plan Information

Welcome Letter ......................................................... 1

Nondiscrimination Provision (1557 Notice) ..............................................................3

Coverage Area ......................................................... 9

Frequently Asked Questions ................................ 11

Product Information

Provider & Pharmacy Directory Web Look Up ........................................................... 17

Plan Chart ................................................................. 19

Rides to Your Doctor .............................................. 21

Fitness Program ..................................................... 23

Making Medicare Work Better for You ......................................................................25

Hearing Care Services ......................................... 27

Summary of Benefits .............................................29

Dental Benefit ........................................................ 35

Enrollment Information

Steps To An Easy Enrollment ...............................51

Understanding Medicare Enrollment Periods ................................................58

Enrollment Verification Notification ...................62

What to Expect After You Enroll ......................... 64

9

COVERAGE AREA

The service area for this plan includes: Wake County. You must live in this area to join the plan.

27502275112751327518275192752327526275292753927540275452756027562

27571275872758827591275922759727601276022760327604276052760627607

27608276092761027612276132761427615276162761727624276352764027695

Wake County

Wake County

11

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 services.

Original Medicare Part B is medical care coverage that helps the costs for doctors’ services, hospital outpatient care and some home health care services, as well as lab tests and durable medical equipment.

Medicare Advantage plans (Medicare Part C) offer similar coverage to Part A (hospital) and Part B (medical), and typically offer additional benefits that may require an additional fee.

Medicare Part D is only offered by private issuers approved by Medicare. Plans help pay for many brand name and generic prescription drugs. You also have access to retail drug stores and mail-order options.

Medicare Advantage and Prescription Drug Plans (MAPD) are plans that offer coverage that includes hospital services as in Part A, medical services as in Part B, and prescription drug coverage as in Part D. Each plan varies in cost and drugs covered.

What is the difference between Medicare Advantage, Part D and Medicare?

FREQUENTLYASKED QUESTIONS

How do I join a FirstMedicare Direct plan?

Our call hours are 8am-8pm Eastern, 7 days a week from October 1 to March 31 and 8am-8pm Monday-Friday from April 1 to September 30.

(855) 903-5154 (TTY users call 711)

12

A Primary Care Physician (PCP) is a doctor you choose to manage all your health care. Your PCP provides preventive and routine care and refers you to specialists and hospitals when needed. A PCP can be an internist, a family or general practitioner. You choose your PCP from the network of doctors in your medical plan.

What is a primary care physician?

If you move out of the Health Plan service area or are away from the service area for more than six months, you cannot remain a member of the Plan. Please call Member Services to find out if you are moving into another FirstMedicare Direct service area.

What do I do if I am planning a move?

Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.

w Your “Personal Health Information” includes the personal information you provide us when you enroll in a plan as well as your medical records and other medical and health information.

w The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a “Notice of Privacy Practice,” that tells about these rights and explains how we protect the privacy of your health information.

How is my private information protected?


If you have lost your card or need a replacement ID card call Member Services at 1-844-499-5630 (TTY users call 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 to Friday (except holidays) from April 1 through September 30.

How do I request a new ID card?

13

You may change your PCP for any reason, at any time. To change your PCP, please call Member Services. We will check to be sure the PCP you want to switch to is accepting new patients. When you call, be sure to let us know if you are seeing a specialist or getting other covered services that need your PCP’s approval and we’ll help make sure that your care continues and will send you a new ID card pending decision.

How do I change my doctor?

People with limited income and resources may qualify for “Extra Help.” Some people automatically qualify for “Extra Help” and don’t need to apply, Medicare will mail a letter to people who automatically qualify for “Extra Help.” You may be able to get “Extra Help” to pay for your prescription drug premiums and costs. To see if you qualify call:

w 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week

w The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778; or Your State Medicaid Office.

How do I know if I qualify for Low Income Assistance?


If you have a medical emergency:

w Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or a referral first from your PCP.

w As soon as possible, make sure that our plan has been told about your emergency. We need to follow up on your emergency care. You or someone else should call to tell us about your emergency care, usually within 48 hours. Please contact Member Services at 1-844-499-5630, 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 to Friday (except holidays) from April 1 through September 30. TTY users call 711. You can reach your doctor by calling the telephone number on the front of your member ID card.

Where do I go for an emergency?

14

“Urgently needed care” is a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be accessed from contracted urgent care centers and contracted hospitals as listed in our Provider Directory.

However, if the circumstances are unusual or extraordinary, and network providers are temporarily unavailable or inaccessible, we will cover urgently needed care that you get from an out-of-network provider.

What is Urgently Needed Care services and how do I obtain access?


If you are outside the service area and cannot get care from a network provider, our plan will cover urgently needed care that you get from any provider. Our plan also covers urgently needed care if you receive the care outside of the United States (limitations and co-insurance may apply).

What if I am outside the plan’s service area and I have an urgent need for care?

There are some services and items we do not cover under any condition and some that are excluded only under specific conditions.

If you get benefits that are excluded, neither we nor Original Medicare will cover the services, you must pay for them yourself. The only exception is if a benefit on the exclusion list is found upon appeal to be a medical benefit that we should have paid for or covered because of your specific situation.

The following are some items and services that are not covered under Original Medicare or by our plan:

w Services considered not reasonable and necessary, according to the standards of Original Medicare, unless these services are listed by our plan as covered services. Experimental medical and surgical procedures, equipment and medications, unless covered by Original Medicare or under a Medicare-approved clinical research study or by our plan.

w Surgical treatment for morbid obesity, except when it is considered medically necessary and covered under Original Medicare.

w Private room in a hospital, except when it is considered medically necessary.

What benefits are NOT covered by the plan?

15

w Private duty nurses.

w Personal items in your room at a hospital or a skilled nursing facility, such as a telephone or a television.

w Full-time nursing care in your home.

w Custodial care is care provided in a nursing home, hospice, or other facility setting when you do not require skilled medical care or skilled nursing care. Custodial care is personal care that does not require the continuing attention of trained medical or paramedical personnel, such as care that helps you with activities of daily living, such as bathing or dressing.

w Homemaker services include basic household assistance, including light housekeeping or light meal preparation.

w Fees charged by your immediate relatives or members of your household.

w Meals delivered to your home.

w Elective or voluntary enhancement procedures or services (including weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, Anti-aging and mental performance), except when medically necessary.

w Cosmetic surgery or procedures, unless caused by an accidental injury or to improve a malformed part of the body. However, all stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance.

w Chiropractic care is generally not covered, other than manual manipulation of the spine consistent with Medicare coverage guidelines.

w Orthopedic shoes, unless the shoes are for a person with diabetic foot disease.

w Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease.

w Radial keratotomy, LASIK surgery, vision therapy and other low vision aids. However, eyeglasses are covered for people after cataract surgery.

What benefits are NOT covered by the plan? (continued)


16

w Reversal of sterilization procedures and non-prescription contraceptive supplies.

w Naturopath services (uses natural or alternative treatments)

w Services provided to veterans in Veterans Affairs (VA) facilities. However, when emergency services are received at a VA hospital and the VA cost sharing is more than the cost sharing under our plan, we will reimburse veterans for the difference. Members are still responsible for our cost sharing amounts.

What benefits are NOT covered by the plan? (continued)


Additional Questions?

Call Member Services (844) 499-5630 (TTY users call 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 to Friday (except holidays) from April 1 through September 30.

17

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 2020 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.

How do I locate these documents?1. Go to our FirstMedicare Direct website at:

www.FirstMedicare.com

2. Choose your County (e.g. Buncombe, Moore, Wake, etc.)

3. Select the “Members” tab

• For the Evidence of Coverage, choose “Coverage Documents” and click on the 2020 Evidence of Coverage for your plan.

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

• 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.

• 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 1-844-499-5630 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.

Y0094_20002_C FMDApproved_08/12/2019

19

2020 BENEFIT FirstMedicare Direct smartHMO

Premium $0

Doctor/SpecialistPCP: $0 copay Specialist: $35 copay

Inpatient HospitalizationPrior Authorization required

$150 copay days 1-5$0 copay days 6-90(unlimited days)

Emergency Care/ Post-Stabilization Care

$80 copay(waived if admitted within 24 hours)

Urgent Care$0 copay(In and Out of Network)

Worldwide Coverage$80 copayUp to $25,000 per year (copay waived if admitted)

AmbulanceGround and Air

$100 copay - Ground$400 copay - Air

Transportation$0 copay24 one-way trips to plan approved locations(within a 20 mile radius)

Durable Medical Equipment

20% co-insurance

Health Club/Fitness Class Membership

$0 copay

Vision Services$0-$45 copay for routine eye exams (up to 1 every year)$0 copay for glasses/contacts every 2 years with a $75 coverage limit.

Hearing Services $0-$45 copay for Medicare-covered benefits

Dental ServicesCoveredRefer to your Summary of Benefits for details.

BENEFITS CHART 2020WAKE COUNTY PLAN

H6306_20021_M_Accepted_09/17/2019

20

PRESCRIPTION DRUG BENEFITS (30 day retail supply)

Part D Deductible $0 deductible

Tier 1, Preferred Generic Drugs, Coverage through the Gap

$0 copay

Tier 2, Generic Drugs $10 copay

Tier 3, Preferred Brand Drugs $47 copay

Tier 4, Non-Preferred Drugs $100 copay

Tier 5, Specialty Drugs 33% co-insurance

Tier 6, Select Care DrugsCoverage Through the Gap

$10 copay

FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO health plans with Medicare contracts. Enrollment in FirstMedicare Direct depends on 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.H6306_20021_M_Accepted_09/17/2019

21

$0 Copay

FirstMedicare Direct smartHMO

offers enrolled Members

transportation coverage to the

doctor and other medically

approved appointments at no

additional cost!

This benefit is only available for

FirstMedicare Direct members.

Limits on rides vary by plan. For

better service and to ensure

availability, appointments must be

scheduled more than 48 hours

in advance.

Transportation Benefit only available in Wake County.

RIDES TO YOUR DOCTOR & MORE

We have a dedicated transportation phone line for our members to call:

(844) 227-7613 TTY Users Call 711

Monday through Friday, 8:00 am to 6:00 pm, Eastern Time

23

FITNESSPROGRAMIt’s easy to stay fit, have fun and make new

friends with FirstMedicare Direct. Learn how

FirstMedicare Direct is dedicated to helping you

stay healthy.

Remember: Check with your physician first before beginning any new exercise programs!

For More Information

Call Member Services (844) 499-5630 TTY Users Call 711


25

MAKING MEDICARE WORK BETTER FOR YOUFirstMedicare Direct is a new kind of healthcare organization that puts the focus back where it belongs on members like you.

We supercharge our partner providers and affiliated health plans, giving them new tools, resources and technology to be smarter, more organized and more efficient. The result is a better Medicare experience with an entire team of coordinated care providers managing your health like never before.

Centers in your area are home to a wide array of preventive health services, as well as the dedicated clinical teams, that act in coordination with your personal physician to provide needed treatment, screenings and care.

What does a Jump Start appointment include?

w A head-to-toe health assessment

w Lab work: blood and urine collection

w Review of your current and past medical history

w Review of medications, including any over-the-counter (OTC) drugs and vitamins you’re taking

w Assessment to determine other health needs or screenings as needed to address your unique health concerns

27

$0 - $45 for diagnostic hearing exams

FirstMedicare Direct offers hearing services. As a member you will receive a yearly hearing exam. We also offer hearing aids, maintenance and supplies at a discounted rate.

HEARING CARE SERVICES

For More Information About This Benefit



29

2020 SUMMARY OF BENEFITS

Summary of Benefits January 1, 2020 - December 31, 2020

FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO health plans with a Medicare contract. Enrollment in FirstMedicare Direct depends on contract renewal. The benefit information provided does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the “Evidence of Coverage.”

To join smartHMO (HMO) you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in North Carolina: Wake County.

Except in emergency situations, if you use the providers that are not in our network, we may not pay for these services.

For coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486.2048.

This document is available in other formats such as Braille or large print.

For more information, please contact us at (855) 903-5154 (TTY users should call 711), visit us at www.FirstMedicare.com.

FIRSTMEDICARE DIRECT

smartHMO H6306-005

H6306_20017_M Accepted 09/14/2019

30


WHAT YOU SHOULD KNOW

Services with a 1 may require prior authorization.Services with a 2 may require a referral from your doctor.

Monthly Plan Premium You pay $0 You must continue to pay your Part B premium.

Part C Deductible You pay $0

Max. Out-of-Pocket Limit (does not include prescription drugs)

You pay $3,400 annually The most you pay for copayments, coinsurance, and other costs of medical services for the year.

Inpatient Hospital Care1, 2 You pay $150 copay days 1-5 You pay $0 copay days 6-90 (unlimited days)

Outpatient Hospital Services1, 2

• Ambulatory Surgical Center• Outpatient Hospital

You pay $100 copayYou pay $150 copay

Doctor Visits Primary Care You pay $0 copay

Doctor Visits Specialist1, 2 You pay $35 copay

Preventive Care You pay $0 copay Includes but not limited to Medicare-covered: glaucoma screening, diabetes self-management training, barium enemas, digital exams, EKG following Welcome Visit and other preventive services.

Annual Physical Exam You pay $0 copay per one annual visit

Emergency Care/ Post-Stabilization Care

You pay $80 copay Copay waived if admitted within 24 hours

Worldwide Emergency You pay $80 copay You pay up to $25,000 max Copay waived if admitted

Urgently Needed Services You pay $0 copay

Diagnostic Tests, Lab1, 2 Therapeutic Radiology Services1, 2

You pay $0-$295 copay (X-Ray/Diagnostic) You pay 20% of the total cost co-insurance or $40 copay (Therapeutic)

Cost share for Therapeutic Radiology is based on place of service.

Hearing Services1, 2 You pay $0-$45 copay for Medicare-covered Benefits

Exam to diagnose and treat hearing and balance issues

Preventive Dental Services• Oral exam & cleaning every

six months• Fluoride treatment, one every

six months• X-ray, one every three years

You pay nothing

You pay $0-$20 copay You pay $0-$30 copay

31


WHAT YOU SHOULD KNOW

Medicare-covered Dental Services1, 2

You pay $0-425 copay

Vision Services1 You pay $0-$45 copay Medicare-covered eye benefits

Exams to diagnose and treat eye diseases/conditions

Outpatient Mental Health1, 2 You pay $40 copay Group or individual therapy visits

Inpatient Mental Health Care1, 2 You pay $295 copay days 1-5You pay $0 copay days 6-90

Skilled Nursing Facility (SNF)1, 2 You pay $0 copay days 1-20 $100 copay per day days 21-100

Outpatient Rehabilitation Services 1, 2

You pay $10-$40 copay Occupational, physical, speech and language therapies.

Ambulance1

Ground and Air TransportationYou pay $100 copay - GroundYou pay $400 copay - Air

Medically necessary ground or air medical transportation. Authorization required for non-emergency services.Copay is NOT waived if admitted.

Transportation1, 2 You pay $0 copay 24 one way trips to plan approved locations every year (within a 20-mile radius from your permanent residence)

Medicare Part B Drugs1 You pay 20% of the total cost

Cardiac Rehabilitation Services1, 2

You pay $10 copay Also includes Intensive Cardiac Rehabilitation Services

Fitness Center Membership You pay $0 copay With plan contracted gym

32

OUTPATIENT PRESCRIPTION DRUGS

Part D Deductible $0

TIERS RETAIL STANDARD MAIL ORDER STANDARD LONG TERM CARE

Tier 1, Preferred Generic Drugs

$0 copay 30 day supply $0 copay 90 day supply


Long Term Care $0 copay 31 day supply

Tier 2, Non-Preferred Generic Drugs




Tier 3, Preferred Brand Drugs




Tier 4, Non-Preferred Drugs




Tier 5, Specialty Drugs

33% coinsurance 30 day supply onlyUnavailable for 90 day supply

33% coinsurance 30 day supply onlyUnavailable for 90 day supply

Long Term Care 33% coinsurance 31 day supply

Tier 6, Select Care Drugs

$10 copay 30 day supply $10 copay 60 day supply $0 copay 90 day supply

$10 copay 30 day supply $10 copay 60 day supply $0 copay 90 day supply


Initial Coverage Limit

$4,020

Gap Coverage Coverage through the gap Tier 1: All Drugs Tier 6: All Drugs

Cost-Sharing may change depending on the pharmacy you choose and when you enter another of the four phases 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.

Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.

This information is not a complete description of benefits. For more information, if you are a member, please call Member Services toll free at (844) 499-5630 Eastern (TTY users call 711). If you are not a member call us toll free at (855) 903-5154 (TTY 711). 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.

33

PRE-ENROLLMENTCHECKLIST

UNDERSTANDING THE BENEFITS

Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely see a doctor. Visit www.FirstMedicare.com to view or call 1-855-903-5154 for a copy of the EOC.

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

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

UNDERSTANDING IMPORTANT RULES

In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.

Benefits, premiums and/or copayments/co-insurance may change on January 1, 2021.

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

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 1-855-903-5154.

Y0094_20005_C_FMD Approved_08/14/2019

35

DENTAL BENEFIT

H6306_20022_M_Accepted_09/17/2019

36

LIBERTYDENTAL BENEFITHIGHLIGHTSThe benefit information provided is a brief summary, not a complete description of benefits. Please refer to your Dental Directory for a complete listing of covered/excluded benefits, dental providers and access to care.

FirstMedicare Direct proudly offers dental services through LIBERTY Dental Plan. This comprehensive dental plan has no monthly premium, no deductibles and low cost co-payments for more than 250 procedures that include checkups, cleanings, gum care, and restorative work. Attached is a list of the dental benefits available to you.

How to Receive Care

Dental benefits are covered only if they are provided by a contracted LIBERTY Dental Plan Guardian Network provider. The only time you may receive care outside of the LIBERTY Dental Plan Guardian Network is for emergency dental services described later in this section. Remember to always check with your dental office before receiving services to make sure the office is a LIBERTY Dental Plan Guardian network provider.

Emergency Dental Care

All affiliated LIBERTY Dental Plan primary care dental offices provide emergency dental services 24 hours a day, 7 days a week.

In the event you require emergency dental care, contact your Primary Care Dentist to schedule an immediate appointment. For urgent or unexpected dental conditions that occur afterhours or on weekends, contact your Primary Care Dentist for instructions on how to proceed.

If your Primary Care Dentist is unavailable, simply contact any licensed dentist to receive care. LIBERTY Dental Plan will reimburse you for dental expenses up to a maximum of $75, less applicable co-payments.

37

FirstMedicare Direct provides coverage for emergency dental services only if the services are required to alleviate severe pain or bleeding, or if you reasonably believe that the condition, if not diagnosed or treated, may lead to disability, dysfunction or permanent damage to your health.

How to Obtain Emergency Dental Care

Emergency dental services and care which are covered by LIBERTY Dental Plan include, as defined in the Health & Safety Code, a dental screening, an examination, an evaluation by a dentist or a dental specialist to determine if an emergency dental condition exists, and to provide care that would be acknowledged as within professionally recognized standards of care and in order to alleviate any emergency symptoms in a dental office. Medical and/ or psychiatric emergencies are not covered by LIBERTY Dental Plan if the services are rendered in a hospital setting which are covered by FirstMedicare Direct, or if LIBERTY Dental Plan determines the services were not dental in nature

At the time of your appointment, your dentist may recommend other dental procedures that are not covered benefits. Services that are not covered can include implants, specialized metals used for fillings and crowns, or other services. If your dentist recommends dental services not covered by this plan, you can talk with your dentist to see if there are other treatment options that are covered. If you choose to accept dental services that are not covered by this plan, you will need to pay for those services.

For more information about your dental benefits, call LIBERTY Dental Plan’s Member Services Department toll-free at 1-888-273-3183, Monday through Friday between the hours of 8:00 am and 5:00 pm. Hearing or speech impaired members may call TTY/TDD 1-800-735-2929.

38

CDT CODE DESCRIPTIONMEMBER CO-PAYMENT LIMITATIONS

DIAGNOSTIC SERVICES

D0120 Periodic oral evaluation $0.00

D0140 Limited oral evaluation $0.00

D0150 Comprehensive oral evaluation $0.00

D0160 Oral evaluation, problem focused $0.00

D0170 Re-evaluation, limited, problem focused

$0.00

D0171 Re-evaluation, post operative office visit

$0.00

D0180 Comprehensive periodontal evaluation

$0.00

D0210 Intraoral, complete series of radiographic images

$0.00 1 every 36 months

D0220 Intraoral, periapical, first radiographic image

$2.00

D0230 Intraoral, periapical, each add ‘l radiographic image

$2.00

D0240 Intraoral, occlusal radiographic image

$5.00

COVERED BENEFITS, MEMBER CO-PAYMENTS, & LIMITATIONS

No Annual Deductible

No Annual Dollar Amount Maximum

• Provider office pre-assignment is not required. However, members must visit a LIBERTY Dental Plan contracted dental office to utilize covered benefits. Your dental office will initiate a treatment plan or will initiate the specialty referral process with LIBERTY Dental Plan if the services are dentally necessary and outside the scope of general dentistry.

• Member co-payments are payable to the dental office at the time services are rendered.

• This Schedule does not guarantee benefits. All services are subject to eligibility and dental necessity at the time of service.

• Dental procedures not listed as covered benefits are available at the dental office's usual and customary fee.

39


D0250 Extra-oral 2D projection radiographic image, stationary radiation source

$15.00

D0251 Extra-oral posterior dental radiographic image

$8.00

D0270 Bitewing, single radiographic image

$2.00

D0272 Bitewings, two radiographic images

$2.00

D0273 Bitewings, three radiographic images

$5.00

D0274 Bitewings, four radiographic images

$2.00

D0277 Vertical bitewings, 7 to 8 radiographic images

$30.00

D0330 Panoramic radiographic image $10.00

D0350 2D oral/facial photographic image, intra-orally/extra-orally

$10.00

D0460 Pulp vitality tests $10.00

D0470 Diagnostic casts $20.00

PREVENTIVE SERVICES

D1110 Prophylaxis, adult $0.00 1 every 6 months

D1208 Topical application of fluoride, excluding varnish

$0.00 1 every 6 months

D1351 Sealant, per tooth $10.00 Only covered on the 1st and 2nd permanent molars and up to the 14th birth date

D1352 Preventive resin restoration, permanent tooth

$10.00

D1353 Sealant repair, per tooth $0.00

D1510 Space maintainer, fixed, unilateral $292.00

D1516 Space maintainer – fixed – bilateral, maxillary

$350.00

D1517 Space maintainer – fixed – bilateral, mandibular

$350.00

D1520 Space maintainer, removable, unilateral

$292.00

D1526 Space maintainer – removable – bilateral, maxillary

$350.00

D1527 Space maintainer – removable – bilateral, mandibular

$350.00

D1550 Re-cement or re-bond space maintainer

$54.00

D1555 Removal of fixed space maintainer $38.00

40


D1575 Distal shoe space maintainer, fixed, unilateral

$292.00

RESTORATIVE SERVICES

D2140 Amalgam, one surface, primary or permanent

$106.00

D2150 Amalgam, two surfaces, primary or permanent

$136.00

D2160 Amalgam, three surfaces, primary or permanent

$164.00

D2161 Amalgam, four or more surfaces, primary or permanent

$193.00

D2330 Resin-based composite, one surface, anterior

$127.00

D2331 Resin-based composite, two surfaces, anterior

$156.00

D2332 Resin-based composite, three surfaces, anterior

$190.00

D2335 Resin-based composite, four or more surfaces, involving incisal angle

$230.00

D2390 Resin-based composite crown, anterior

$234.00

D2391 Resin-based composite, one surface, posterior

$142.00

D2392 Resin-based composite, two surfaces, posterior

$179.00

D2393 Resin-based composite, three surfaces, posterior

$215.00

D2394 Resin-based composite, four or more surfaces, posterior

$226.00

D2510 Inlay, metallic, one surface $350.00* 1 per tooth every 5 year period

D2520 Inlay, metallic, two surfaces $350.00* 1 per tooth every 5 year period

D2530 Inlay, metallic, three or more surfaces

$350.00* 1 per tooth every 5 year period

D2542 Onlay, metallic, two surfaces $350.00* 1 per tooth every 5 year period

D2543 Onlay, metallic, three surfaces $350.00* 1 per tooth every 5 year period

D2544 Onlay, metallic, four or more surfaces


D2610 Inlay, porcelain/ceramic, one surface

$350.00 1 per tooth every 5 year period

D2620 Inlay, porcelain/ceramic, two surfaces


D2630 Inlay, porcelain/ceramic, three or more surfaces


D2642 Onlay, porcelain/ceramic, two surfaces


41


D2643 Onlay, porcelain/ceramic, three surfaces


D2644 Onlay, porcelain/ceramic, four or more surfaces


D2650 Inlay, resin-based composite, one surface


D2651 Inlay, resin-based composite, two surfaces


D2652 Inlay, resin-based composite, three or more surfaces


D2662 Onlay, resin-based composite, two surfaces


D2663 Onlay, resin-based composite, three surfaces


D2664 Onlay, resin-based composite, four or more surfaces


D2710 Crown, resin-based composite (indirect)


D2720 Crown, resin with high noble metal $350.00* 1 per tooth every 5 year period

D2721 Crown, resin with predominantly base metal


D2722 Crown, resin with noble metal $350.00* 1 per tooth every 5 year period

D2740 Crown, porcelain/ceramic $350.00 1 per tooth every 5 year period

D2750 Crown, porcelain fused to high noble metal


D2751 Crown, porcelain fused to predominantly base metal


D2752 Crown, porcelain fused to noble metal


D2780 Crown, ¾ cast high noble metal $350.00* 1 per tooth every 5 year period

D2781 Crown, ¾ cast predominantly base metal


D2782 Crown, ¾ cast noble metal $350.00* 1 per tooth every 5 year period

D2790 Crown, full cast high noble metal $350.00* 1 per tooth every 5 year period

D2791 Crown, full cast predominantly base metal


D2792 Crown, full cast noble metal $350.00* 1 per tooth every 5 year period

D2794 Crown, titanium $350.00* 1 per tooth every 5 year period

D2799 Provisional crown $283.00

D2910 Re-cement or re-bond inlay, onlay, veneer, or partial coverage

$20.00

D2915 Re-cement or re-bond indirectly fabricated/prefabricated post & core

$86.00

D2920 Re-cement or re-bond crown $82.00

42


D2930 Prefabricated stainless steel crown, primary tooth

$234.00

D2931 Prefabricated stainless steel crown, permanent tooth

$270.00

D2932 Prefabricated resin crown $283.00

D2933 Prefabricated stainless steel crown with resin window

$283.00

D2940 Protective restoration $89.00

D2950 Core buildup, including any pins when required

$209.00

D2951 Pin retention, per tooth, in addition to restoration

$41.00

D2952 Post and core in addition to crown, indirectly fabricated

$312.00

D2953 Each additional indirectly fabricated post, same tooth

$24.00

D2954 Prefabricated post and core in addition to crown

$252.00

D2955 Post removal $203.00

D2957 Each additional prefabricated post, same tooth

$18.00

D2980 Crown repair necessitated by restorative material failure

$203.00

ENDODONTIC SERVICES

D3110 Pulp cap, direct (excluding final restoration)

$15.00

D3120 Pulp cap, indirect (excluding final restoration)

$15.00

D3220 Therapeutic pulpotomy (excluding final restoration)

$163.00

D3230 Pulpal therapy, anterior, primary tooth (excluding final restoration)

$172.00

D3240 Pulpal therapy, posterior, primary tooth (excluding finale restoration)

$187.00

D3310 Endodontic therapy, anterior tooth (excluding final restoration)

$375.00

D3320 Endodontic therapy, premolar tooth (excluding final restoration)

$375.00

D3330 Endodontic therapy, molar tooth (excluding final restoration)

$375.00

D3346 Retreatment of previous root canal therapy, anterior

$375.00

D3347 Retreatment of previous root canal therapy, premolar

$375.00

D3348 Retreatment of previous root canal therapy, molar

$375.00

43


D3351 Apexification/recalcification, initial visit

$194.00

D3352 Apexification/recalcification, interim medication replacement

$130.00

D3353 Apexification/recalcification, final visit

$375.00

D3355 Pulpal regeneration, initial visit $194.00

D3356 Pulpal regeneration, interim medication replacement

$130.00

D3357 Pulpal regeneration, completion of treatment

$130.00

D3410 Apicoectomy, anterior $375.00

D3421 Apicoectomy, premolar (first root) $375.00

D3425 Apicoectomy, molar (first root) $375.00

D3426 Apicoectomy, (each additional root)

$258.00

D3428 Bone graft in conjunction with periradicular surgery, per tooth, single site

$375.00

D3429 Bone graft in conjunction with periradicular surgery, each add’l tooth, same site

$274.00

D3430 Retrograde filling, per root $168.00

D3450 Root amputation, per root $375.00

D3920 Hemisection, not including root canal therapy

$288.00

D3950 Canal preparation and fitting of preformed dowel or post

$97.00

PERIODONTAL SERVICES

D4210 Gingivectomy or gingivoplasty, four or more teeth per quadrant

$375.00

D4211 Gingivectomy or gingivoplasty, one to three teeth per quadrant

$212.00

D4212 Gingivectomy or gingivoplasty, restorative procedure, per tooth

$149.00

D4240 Gingival flap procedure, four or more teeth per quadrant

$375.00

D4241 Gingival flap procedure, one to three teeth per quadrant

$375.00

D4260 Osseous surgery, four or more teeth per quadrant

$375.00

D4261 Osseous surgery, one to three teeth per quadrant

$375.00

D4263 Bone replacement graft, retained natural tooth, first site, quadrant

$375.00

44


D4264 Bone replacement graft, retained natural tooth, each additional site

$274.00

D4266 Guided tissue regeneration, resorbable barrier, per site

$330.00

D4267 Guided tissue regeneration, non-resorbable barrier, per site

$375.00

D4268 Surgical revision procedure, per tooth

$212.00

D4274 Mesial/distal wedge procedure, single tooth

$375.00

D4341 Periodontal scaling and root planing, four or more teeth per quadrant

$200.00

D4342 Periodontal scaling and root planing, one to three teeth per quadrant

$140.00

D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis, subsequent visit

$127.00

D4381 Localized delivery of antimicrobial agent/per tooth

$78.00

D4910 Periodontal maintenance $114.00

D4921 Gingival irrigation, per quadrant $62.00

REMOVABLE PROSTHODONTIC SERVICES

D5110 Complete denture, maxillary $425.00 1 per arch every 5 year period

D5120 Complete denture, mandibular $425.00 1 per arch every 5 year period

D5130 Immediate denture, maxillary $425.00 1 per arch every 5 year period

D5140 Immediate denture, mandibular $425.00 1 per arch every 5 year period

D5211 Maxillary partial denture, resin base

$425.00 1 per arch every 5 year period

D5212 Mandibular partial denture, resin base


D5213 Maxillary partial denture, cast metal, resin base


D5214 Mandibular partial denture, cast metal, resin base


D5221 Immediate maxillary partial denture, resin base


D5222 Immediate mandibular partial denture, resin base


D5223 Immediate maxillary partial denture, cast metal framework, resin denture base


D5224 Immediate mandibular partial denture, cast metal framework, resin denture base


45


D5282 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), maxillary


D5283 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), mandibular


D5410 Adjust complete denture, maxillary $20.00

D5411 Adjust complete denture, mandibular

$20.00

D5421 Adjust partial denture, maxillary $20.00

D5422 Adjust partial denture, mandibular $20.00

D5511 Repair broken complete denture base, mandibular

$149.00

D5512 Repair broken complete denture base, maxillary

$149.00

D5520 Replace missing or broken teeth, complete denture

$125.00

D5611 Repair resin partial denture base, mandibular

$133.00

D5612 Repair resin partial denture base, maxillary

$133.00

D5621 Repair cast partial framework, mandibular

$199.00

D5622 Repair cast partial framework, maxillary

$199.00

D5630 Repair or replace broken retentive clasping materials – per tooth

$182.00

D5640 Replace broken teeth, per tooth $119.00

D5650 Add tooth to existing partial denture

$148.00

D5660 Add clasp to existing partial denture, per tooth

$166.00

D5710 Rebase complete maxillary denture

$425.00

D5711 Rebase complete mandibular denture

$425.00

D5720 Rebase maxillary partial denture $390.00

D5721 Rebase mandibular partial denture $390.00

D5730 Reline complete maxillary denture, chairside


D5731 Reline complete mandibular denture, chairside


D5740 Reline maxillary partial denture, chairside


46


D5741 Reline mandibular partial denture, chairside


D5750 Reline complete maxillary denture, laboratory


D5751 Reline complete mandibular denture, laboratory


D5760 Reline maxillary partial denture, laboratory


D5761 Reline mandibular partial denture, laboratory


D5810 Interim complete denture, maxillary


D5811 Interim complete denture, mandibular


D5820 Interim partial denture, maxillary $425.00 1 per arch every 5 year period

D5821 Interim partial denture, mandibular $425.00 1 per arch every 5 year period

D5850 Tissue conditioning, maxillary $114.00

D5851 Tissue conditioning, mandibular $114.00

D5911 Facial moulage (sectional) $179.00

D5912 Facial moulage (complete) $179.00

D5992 Adjust maxillofacial prosthetic appliance, by report

$76.00

IMPLANT SERVICES

D6092 Re-cement or re-bond implant/abutment supported crown

$82.00

D6093 Re-cement or re-bond implant/abutment supported FPD

$119.00

FIXED PROSTHODONTIC SERVICES

D6205 Pontic, indirect resin based composite


D6210 Pontic, cast high noble metal $425.00* 1 per tooth every 5 year period

D6211 Pontic, cast predominantly base metal


D6212 Pontic, cast noble metal $425.00* 1 per tooth every 5 year period

D6214 Pontic, titanium $425.00* 1 per tooth every 5 year period

D6240 Pontic, porcelain fused to high noble metal


D6241 Pontic, porcelain fused to predominantly base metal


D6242 Pontic, porcelain fused to noble metal


D6250 Pontic, resin with high noble metal $425.00* 1 per tooth every 5 year period

D6251 Pontic, resin with predominantly base metal


47


D6252 Pontic, resin with noble metal $425.00* 1 per tooth every 5 year period

D6545 Retainer, cast metal for resin bonded fixed prosthesis


D6549 Resin retainer, for resin bonded fixed prosthesis


D6720 Retainer crown, resin with high noble metal


D6721 Retainer crown, resin with predominantly base metal


D6722 Retainer crown, resin with noble metal


D6750 Retainer crown, porcelain fused to high noble metal


D6751 Retainer crown, porcelain fused to predominantly base metal


D6752 Retainer crown, porcelain fused to noble metal


D6780 Retainer crown, ¾ cast high noble metal


D6781 Retainer crown, ¾ cast predominantly base metal


D6782 Retainer crown, ¾ cast noble metal


D6790 Retainer crown, full cast high noble metal


D6791 Retainer crown, full cast predominantly base metal


D6792 Retainer crown, full cast noble metal


D6794 Retainer crown, titanium $425.00* 1 per tooth every 5 year period

D6930 Re-cement or re-bond fixed partial denture

$119.00

D6940 Stress breaker $236.00

D6980 Fixed partial denture repair, restorative material failure

$174.00

ORAL & MAXILLOFACIAL SERVICES

D7140 Extraction, erupted tooth or exposed root

$126.00

D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth

$216.00

D7220 Removal of impacted tooth, soft tissue

$300.00

D7230 Removal of impacted tooth, partially bony

$342.00

48


D7240 Removal of impacted tooth, completely bony

$396.00

D7241 Removal impacted tooth, complete bony, complication

$425.00

D7250 Removal of residual tooth roots (cutting procedure)

$218.00

D7260 Oroantral fistula closure $425.00

D7270 Tooth reimplantation and/or stabilization, accident

$425.00

D7280 Exposure of an unerupted tooth $425.00

D7285 Incisional biopsy of oral tissue, hard (bone, tooth)

$425.00

D7286 Incisional biopsy of oral tissue, soft $314.00

D7288 Brush biopsy, transepithelial sample collection

$157.00

D7310 Alveoloplasty with extractions, four or more teeth per quadrant

$199.00

D7311 Alveoloplasty with extractions, one to three teeth per quadrant

$100.00

D7320 Alveoloplasty, w/o extractions, four or more teeth per quadrant

$222.00

D7321 Alveoloplasty, w/o extractions, one to three teeth per quadrant

$156.00

D7410 Excision of benign lesion, up to 1.25 cm

$347.00

D7411 Excision of benign lesion, greater than 1.25 cm

$425.00

D7471 Removal of lateral exostosis, maxilla or mandible

$425.00

D7510 Incision & drainage of abscess, intraoral soft tissue

$168.00

D7520 Incision & drainage of abscess, extraoral soft tissue

$202.00

D7960 Frenulectomy (frenectomy or frenotomy), separate procedure

$388.00

D7970 Excision of hyperplastic tissue, per arch

$425.00

D7971 Excision of pericoronal gingiva $193.00

ADJUNCTIVE GENERAL SERVICES

D9110 Palliative (emergency) treatment, minor procedure

$80.00

D9211 Regional block anesthesia $329.00

D9212 Trigeminal division block anesthesia

$113.00

49


D9215 Local anesthesia in conjunction with operative or surgical procedures

$0.00

D9310 Consultation, other than requesting dentist

$83.00

D9311 Consultation with a medical health care professional

$0.00

D9440 Office visit, after regularly scheduled hours

$94.00

D9944 Occlusal guard – hard appliance, full arch

$425.00

D9945 Occlusal guard – soft appliance, full arch

$425.00

D9946 Occlusal guard – hard appliance, partial arch

$425.00

D9942 Repair and/or reline of occlusal guard

$88.00

D9951 Occlusal adjustment, limited $89.00

D9952 Occlusal adjustment, complete $414.00

D9971 Odontoplasty 1-2 teeth; includes removal of enamel projections

$89.00

D9991 Dental case management, addressing appointment compliance barriers

$0.00

D9992 Dental case management, care coordination

$0.00

D9993 Dental case management, motivational interviewing

$0.00

D9994 Dental case management, patient education to improve oral health literacy

$0.00

*Resin, porcelain and any resin metal or porcelain to metal crowns and pontics are a benefit on anterior (teeth numbers 6-11, 22-27), first bicuspid (teeth numbers 5, 12, 21, and 28) and second bicuspids (teeth numbers 4, 13, 20, and 29) teeth only. The member will be charged the additional lab cost to add resin or porcelain to all molar (teeth numbers 1-3, 14-19, 30-32) crowns and pontics. Exception: Implants and all services associated with implants are listed at the actual member co-payment amount. No Additional fee is allowable for resin or porcelain for procedures associated with implants.

The maximum amount chargeable to the member to upgrade to resin or porcelain on molar teeth (teeth numbers 1-3, 14-19, 30-32) and/or upgrade to noble metal, high noble metal, Titanium alloy or titanium is $250.00.

50

EXCLUSIONS

1. Any procedure not specifically listed as a Covered Benefit.

2. Replacement of lost or stolen prosthetics or appliances including crowns, bridges, partial dentures, full dentures, and orthodontic appliances.

3. Any treatment requested, or appliances made, which are either not necessary for maintaining or improving dental health, or are for cosmetic purposes unless otherwise covered as a benefit.

4. Procedures considered experimental, treatment involving implants or pharmacological regimens other than listed as Covered Benefit (See “Independent Medical Review” in the Group Evidence of Coverage and Disclosure Form).

5. Oral surgery requiring the setting of bone fractures or bone dislocations.

6. Hospitalization.

7. Out-patient services.

8. Ambulance services.

9. Durable Medical Equipment.

10. Mental Health services.

11. Chemical Dependency services.

12. Home Health services.

13. General anesthesia, analgesia, intravenous/intramuscular sedation or the services of an anesthesiologist other than listed as Covered Benefit.

14. Treatment started before the member was eligible, or after the member was no longer eligible.

15. Procedures, appliances, or restorations to correct congenital, developmental or medically induced dental disorder, including but not limited to: myofunctional(e.g. speech therapy), myoskeletal, or temporomandibular joint dysfunctions (e.g. adjustments/corrections to the facial bones) unless otherwise covered as an orthodontic benefit.

16. Procedures which are determined not to be dentally necessary consistent with professionally recognized standards of dental practice.

17. Treatment of malignancies, cysts, or neoplasms.

18. Orthodontic treatment started prior to member’s effective date of coverage.

19. Appliances needed to increase vertical dimension or restore occlusion.

20. Any services performed outside of your assigned dental office, unless expressly authorized by Liberty Dental Plan, or unless as outlined and covered in “Emergency Dental Care” section.

FMD-20190111 CDT-2019: Current Dental Terminology, © 2018 American Dental Association. All rights reserved. Making members shine, one smile at a time™

51

Steps to Get Yourself Ready to Enroll

w Your Primary Care Physician

If you would like to select a Primary Care Physician, visit www.FirstMedicare.com to search for a provider. If you do not select a Primary Care Physician at the time of enrollment, one will be assigned to you.

w Your Medicare ID Card You will also need information found on your Medicare card or Medicare entitlement information.

w Enroll by Phone Call FirstMedicare Direct at (855) 903-5154 (TTY users call 711) 8:00 a.m. to 8:00 p.m. Eastern, seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

w Enroll by Mail Fill out the enclosed application form completely and mail to:

FirstMedicare Direct 42 Memorial Drive Pinehurst, NC 28374

w Enroll Online Medicare beneficiaries may also enroll in FirstMedicare Direct through our website. Please visit www.FirstMedicare.com to complete our online enrollment form. Medicare beneficiaries may also enroll in FirstMedicare Direct through the CMS Medicare Online Enrollment Center located at https://www.medicare.gov

STEPS TO EASY ENROLLMENT

Additional Questions?



H6306_20010_M 1

2020 Medicare Advantage Prescription Drug Plan (MAPD) Individual Enrollment Form Please contact FirstMedicare Direct if you need information in another language or format (Braille or Large Print).

To Enroll in FirstMedicare Direct Please Provide the Following Information:

Please select your plan: ☐ $0 per month H6306‐005‐00 FirstMedicare Direct smartHMO LAST Name: FIRST Name: Middle Initial: ☐ Mr. ☐ Mrs. ☐ Ms.

Birth Date: / / MM / DD / YYYY

Sex: ☐ M ☐ F

Home Phone Number: ( ) ‐

Alternate Phone Number:

( ) ‐ Permanent Residence Street Address (P.O. Box is not allowed):

City: County:

☐ Wake

State: ZIP Code:

Mailing Address (Only if different from your Permanent Residence Address):

Street Address: City: State: ZIP Code:

E‐mail Address:

Emergency Contact:

Phone Number: Relationship to You:

Please Provide Your Medicare Insurance Information Please take out your red, white and blue Medicare

card to complete this section. Name (as it appears on your Medicare card):

Fill out this information as it appears on

your Medicare card. Medicare Number:

OR Is Entitled To: Effective Date:

Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board.

HOSPITAL (Part A)

MEDICAL (Part B)

You must have Medicare Part A and Part B to join a Medicare Advantage plan.

H6306_20010_M 2

Paying Your Plan Premium If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail, Electronic Funds Transfer (EFT), or credit card each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D‐Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay FirstMedicare Direct the Part D‐IRMAA. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you are eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles and co‐insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call Social Security at 1‐800‐772‐1213. TTY users should call 1‐800‐325‐0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover.

If you don’t select a payment option, you will get a bill each month. Please select a premium payment option:

☐ Get a bill (monthly) in the mail ☐ Electronic Funds Transfer (EFT) ☐ Credit Card

NOTE: If you select Electronic Funds Transfer (EFT) or Credit Card, you will receive information about how to provide your banking/credit card information securely.

☐ Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check.

I get monthly benefits from: ☐ Social Security ☐ RRB (The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

Please read and answer these important questions: 1. Do you have End Stage Renal Disease (ESRD)? ☐ Yes ☐ No If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don’t need dialysis, otherwise we may need to contact you to obtain additional information.

2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits or State pharmaceutical assistance programs. Will you have other prescription drug coverage in addition to FirstMedicare Direct? ☐ Yes ☐ No If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage: Name of other coverage: ID# for this coverage: Group # for this coverage:

H6306_20010_M 3

3. Are you a resident in a long‐term care facility, such as a nursing home? ☐Yes ☐No If “yes,” please provide the following information: Name of Institution:

Address & Phone Number of Institution (number and street):

4. Are you enrolled in your State Medicaid program? ☐Yes ☐No

If yes, please provide your Medicaid number:

5. Do you or your spouse work? ☐Yes ☐No

Please choose the name of a Primary Care Physician (PCP), clinic or health center:

Please check one of the boxes below if you would prefer us to send you information in a language other than English or in an accessible format: ☐ Braille ☐ Large print Please contact FirstMedicare Direct at 1‐844‐201‐4957 if you need information in an accessible format or language other than what is listed above. Our Member Services hours are 8 a.m. to 8 p.m. Eastern seven days a week from October 1, 2019, through March 31, 2020. Beginning April 1, 2020, through September 30, 2020 our Member Services hours are 8 a.m. to 8 p.m. Eastern, Monday through Friday. Persons with hearing impairments please call TTY at 711.

Please Read This Important Information

If you currently have health coverage from an employer or union, joining FirstMedicare Direct, could affect your employer or union health benefits. You could lose your employer or union health coverage if you join FirstMedicare Direct. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Please read and sign below: By completing this enrollment application, I agree to the following: FirstMedicare Direct is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 – December 7 of every year), or under certain special circumstances. FirstMedicare Direct serves a specific service area. If I move out of the area that FirstMedicare Direct serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of FirstMedicare Direct, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from FirstMedicare Direct when I get it to know which rules I must follow to get coverage with this

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Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border. HMO Applicants: I understand that beginning on the date FirstMedicare Direct coverage begins, I must get all of my health care from FirstMedicare Direct, except for emergency or urgently needed services or out‐of‐area dialysis services. PPO Applicants: I understand that beginning on the date FirstMedicare Direct coverage begins, using services in‐network can cost less than using services out‐of‐network, except for emergency or urgently needed services or out‐of‐area dialysis services. If medically necessary, FirstMedicare Direct provides refunds for all covered benefits, even if I get services out of network. Services authorized by FirstMedicare Direct and other services contained in my FirstMedicare Direct Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR FIRSTMEDICARE DIRECT WILL PAY FOR THE SERVICES. I understand that if I am getting assistance from a sales agent, broker or other individual employed by or contracted with FirstMedicare Direct, he/she may be paid based on my enrollment in FirstMedicare Direct. Release of Information: By joining this Medicare health plan, I acknowledge that FirstMedicare Direct will release my information to Medicare and other plans or providers as is necessary for treatment, payment and health care operations. I also acknowledge that FirstMedicare Direct will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare. Signature Today’s Date:

If you are the authorized representative, you must sign above and provide the following information:

Name: Address:

Phone Number: Relationship to Enrollee:

OFFICE USE ONLY: Plan ID# (Contract/Plan#): Effective Date: Mo. /2020 Name of staff member/agent/broker (if assisted in enrollment): Agent No:

ICEP/IEP ☐ AEP ☐ SEP ☐ (type): Not eligible: Notes:

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ATTESTATION OF ELIGIBILITY FOR AN ENROLLMENT PERIOD Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage Plan outside of this period. Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.

☐ I am new to Medicare.

☐ I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP).

☐ I recently moved outside of the service area for my current plan or I recently moved, and this plan is a new option for me. I moved on (insert date):

☐ I recently was released from incarceration. I was released on (insert date):

☐ I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date):

☐ I recently obtained lawful presence status in the United States. I got this status on (insert date):

☐ I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid) on (insert date):

☐ I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change in the level of Extra Help, or lost Extra Help) on (insert date):

☐ I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra Help paying for my Medicare prescription drug coverage, but I haven’t had a change.

☐ I am moving into, live in, or recently moved out of a Long‐Term Care Facility (for example, a nursing home or long‐term care facility). I moved/will move into/out of the facility on (insert date):

☐ I recently left a PACE program on (insert date):

☐ I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost my drug coverage on (insert date):

☐ I am leaving employer or union coverage on (insert date):

☐ I belong to a pharmacy assistance program provided by my state.

☐ My plan is ending its contract with Medicare or Medicare is ending its contract with my plan.

☐ I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My enrollment in that plan started on (insert date):

☐ I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to be in that plan. I was disenrolled from the SNP on (insert date):

☐ I was affected by a weather‐related emergency or major disaster [as declared by the Federal Emergency Management Agency (FEMA)]. One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster.

If none of these statements applies to you or you’re not sure, please contact FirstMedicare Direct at 1‐877‐279‐1732 (TTY users should call 711) to see if you are eligible to enroll. Member Services is available from October 1, 2019 through April 1, 2020 from 8 a.m. to 8 p.m. Eastern seven days a week. Beginning March 31, 2020, through September 30, 2020, we are open from 8 a.m. to 8 p.m. Eastern Monday through Friday.

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UNDERSTANDING MEDICARE ENROLLMENT PERIODSAnnual Enrollment Period (AEP) October 15 through December 7

During this time you can change how you get your Medicare health coverage and enroll in, change or drop Medicare drug coverage.

Medicare Advantage Open Enrollment Period (OEP) January 1 through March 31

During this period if you have a Medicare Advantage plan you can leave your plan and return to Original Medicare or disenroll in your current plan and enroll in a different Medicare Advantage (MAPD Plan).

Initial Coverage Enrollment Period (ICEP)

The Initial Coverage Enrollment Period for Parts A and B is 7 months, starting 3 months before the month of your Medicare eligibility and ending 3 months after the month of eligibility. The month of eligibility is the month of your 65th birthday, if you become eligible for Medicare because you are turning 65 years old. Or, if you become eligible due to a disability, your month of eligibility is the 25th month of receiving Social Security Disability Insurance (SSDI)

Special Enrollment Period (SEP)

Additionally, you can only change how you get your health coverage and enroll in, change or terminate your Part D drug coverage if you qualify for a Special Enrollment Period (SEP) once per calendar quarter during the first three quarters of the year (January – September).

You can make changes to your Medicare Advantage coverage when certain events happen in your life, like if you move or you lose other insurance coverage. These chances to make changes are called Special Enrollment Periods (SEPs). Rules about when you can make changes and the type of changes you can make are different for each SEP.

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2019 Medicare Star Ratings*

The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star Ratings to compare our plan's performance to other plans. The two main types of Star Ratings are:

1. An Overall Star Rating that combines all of our plan's scores.

2. Summary Star Rating that focuses on our medical or our prescription drug services.

Some of the areas Medicare reviews for these ratings include:

• How our members rate our plan's services and care;

• How well our doctors detect illnesses and keep members healthy;

• How well our plan helps our members use recommended and safe prescription medications.

For 2019, FirstMedicare Direct received the following Overall Star Rating from Medicare.

We received the following Summary Star Rating for FirstMedicare Direct's health/drug plan services:

Health Plan Services: 3.5 Stars

Drug Plan Services: 3.5 StarsThe number of stars shows how well our plan performs.

5 stars - excellent 4 stars - above average 3 stars - average 2 stars - below average 1 star - poor

Learn more about our plan and how we are different from other plans at www.medicare.gov.

You may also contact us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time at 855-903-5154 (toll-free) or 711 (TTY), from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time.

Current members please call 844-499-5630 (toll-free) or 711 (TTY).

*Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year to thenext.

3.5 Stars

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Within 15 days after you submit your FirstMedicare Direct application you will receive a notice in the mail explaining the guidelines and procedures of enrolling into a Medicare Advantage plan.

Topics Regarding Your Application Will Include:

w Understanding that you have applied for a Medicare Advantage plan and what that entails.

w Understanding that to enroll with FirstMedicare Direct you must have both Medicare Part A and Medicare Part B.

w Understanding that FirstMedicare Direct offers our members a network of doctors, specialists, hospitals and other providers. You must use plan-approved providers for your healthcare services. Make sure you familiarize yourself with the providers in your area. Our provider listing can change at any time. Visit our website at www.FirstMedicare.com for the most up-to-date list of providers.

w Understanding the materials that you will be receiving as a member of our plan.

w Understanding what a drug formulary is and what it entails.

w Understanding our cancellation policy.

ENROLLMENT VERIFICATION NOTIFICATION

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WHAT TO EXPECT AFTER YOU ENROLLHere is a list of things to expect as a new FirstMedicare Direct Member:

w Enrollment Forms Received by FirstMedicare Direct Once your enrollment is received by FirstMedicare Direct by phone, mail, fax, agent or via the Internet, we will begin the immediate processing of your enrollment into our Medicare Advantage plan.

w Confirmation Within 10 days of enrollment, you will receive a confirmation of enrollment letter in the mail. This letter will also serve as confirmation that Medicare has approved your enrollment form.

w Enrollment Verification Notice Within 15 days of enrollment you will receive a notification by mail or phone explaining the guidelines and procedures of enrolling into a Medicare Advantage plan, this is called the “Outbound Enrollment and Verification Requirements“.

w Member ID Card Before your effective date, you will receive your Member ID card. Bring your new Member ID card with you to all your doctor, hospital and pharmacy visits.

w Welcome to your New Health Plan You will receive a large envelope containing important plan documents. The packet will include the Evidence of Coverage and Dental Directory.

w Extra Help If you qualify for “Extra Help” from the state, you will receive a “LIS” (Low Income Subsidy) letter within 10 days of verified enrollment.

For Enrollment Questions, Please Call:

(855) 903-5154 TTY Users Call 711


W A K E C O U N T YsmartHMO

FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO health plans with Medicare contracts. Enrollment in FirstMedicare Direct depends on 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.

www.FirstMedicare.com(855) 903-5154 • TTY USERS CALL 7118:00 a.m. to 8:00 p.m. Eastern, 7 days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

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