FHCP Medicare Premier Advantage (HMO) 2025

$0 copay

$15 copay

$215 copay per day for days 1-5
$0 copay per day for days 6-90
$0 copay per day for days 91 and beyond

$125 copay, waived if admitted within 24 hours for the same condition.

$0 - $10 copay, depending on the service

$0

Tier 1 - Preferred Generic
Preferred Retail (31-Day): $0 copay
Standard Retail (31-Day): $17 copay
Standard Mail Order (93-Day): $0 copay

Tier 2 - Generic
Preferred Retail (31-Day): $5 copay
Standard Retail (31-Day): $20 copay
Standard Mail Order (93-Day): $12 copay

Tier 3 - Preferred Brand
Preferred Retail (31-Day): $44 copay
Standard Retail (31-Day): $47 copay
Standard Mail Order (93-Day): $129 copay

Tier 4 - Non-Preferred Drug
Preferred Retail (31-Day): $95 copay
Standard Retail (31-Day): $100 copay
Standard Mail Order (93-Day): $282 copay

Tier 5 - Specialty Tier
Preferred Retail (31-Day): 33% coinsurance
Standard Retail (31-Day): 33% coinsurance
Standard Mail Order (93-Day): Not offered

Tier 6 - Vaccines ($0 Cost Sharing)
Preferred Retail (31-Day): $0 copay
Standard Retail (31-Day): $0 copay
Standard Mail Order (93-Day): Not offered

For Generic drugs, you pay:

Tier 1 - Preferred Generic
Preferred Retail (31-Day): $0 copay
Standard Retail (31-Day): $17 copay
Standard Mail Order (93-Day): $0 copay

Tier 2 - Generic
Preferred Retail (31-Day): $5 copay
Standard Retail (31-Day): $20 copay
Standard Mail Order (93-Day): $12 copay

OR
25% of the cost, whichever is less.

For brand name drugs, you pay 25% of the cost (plus a portion of the dispensing fee).

Tier 6 - Vaccines ($0 Cost Sharing)
Preferred Retail (31-Day): $0 copay
Standard Retail (31-Day): $0 copay
Standard Mail Order (93-Day): Not offered

$0 copay

Routine vision
Routine hearing exam
Hearing aid fitting/evaluation
Hearing aids
Preventive dental
Comprehensive dental
Health education
Nutrition classes
Preferred Fitness Program
Telemedicine
Nurse Advice Line
OTC benefit

If you receive care from an out-of network provider without prior authorization from our plan, the care will not be covered except for emergency care, urgently needed care and dialysis services.

We generally cover drugs filled at an out-of-network pharmacy only if you are not able to use one of our network pharmacies (for example, because you are traveling, need emergency or urgent care). Chapter 5 of the Evidence of Coverage provides a full list of situations in which we may cover drugs from an out-of-network pharmacy.