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FHCP Medicare Advantage

FHCP Medicare Premier Advantage (HMO)

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Coverage Summary

Is My Doctor In-Network?	Is My Doctor In-Network?
Primary Care Doctor Visit	$0 copay
Specialist Visit	$15 copay
Inpatient Hospital Care	$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
Emergency Services (In and out-of-network)	$120 copay, waived if admitted within 24 hours for the same condition. Emergency Care, Urgently Needed Services, and Ambulance Services are available worldwide. ER copay waived if admitted within 24 hours for the same condition. $25,000 combined yearly limit for Worldwide Emergency Care, Urgently Needed Services, and Ambulance Services
Urgent Care Services	$0 - $10 copay, depending on the service

Prescription Drug Coverage

Prescription Drug Deductible	$0
In-Network Prescription Drug Coverage - Initial Coverage	Tier 1 - Preferred Generics Preferred Retail (31-Day): $0 copay Standard Retail (31-Day): $17 copay Standard Mail Order (93-Day): $0 copay Tier 2 - Generics Preferred Retail (31-Day): $5 copay Standard Retail (31-Day): $20 copay Standard Mail Order (93-Day): $12 copay Tier 3 - Preferred Brands Preferred Retail (31-Day): $44 copay Standard Retail (31-Day): $47 copay Standard Mail Order (93-Day): $129 copay Tier 4 - Non-Preferred Brands Preferred Retail (31-Day): $95 copay Standard Retail (31-Day): $100 copay Standard Mail Order (93-Day): $282 copay Tier 5 - Specialty Preferred Retail (31-Day): 33% coinsurance Standard Retail (31-Day): 33% coinsurance Standard Mail Order (93-Day): Not offered
Coverage Gap	For Generic drugs, you pay: Tier 1 - Preferred Generics Preferred Retail (31-Day): $0 copay Standard Retail (31-Day): $17 copay Standard Mail Order (93-Day): $0 copay Tier 2 - Generics Preferred Retail (31-Day): $5 copay Standard Retail (31-Day): $20 copay Standard Mail Order (93-Day): $12 copay OR 25% of the costs, whichever is lower. For brand name drugs, you pay 25% of the price for brand name drugs (plus a portion of the dispensing fee).
Catastrophic Coverage	You pay the greater of $3.95 or 5% for generic drugs and drugs treated like generics. You pay the greater of $9.85 or 5% for brand name drugs.

Extra Coverage

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

Out of Network Coverage

Medical Services/Supplies	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.
Prescription Drugs	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.

Plan Documents

Summary of Benefits (PDF)	English Last Updated: 8/23/2021
Evidence of Coverage (PDF)	English Last Updated: 8/30/2021
Plan Rating (PDF)	English Last Updated: 10/16/2021
General Transition Notice (PDF)	English Last Updated: 7/1/2021
Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF)	English Last Updated: 9/24/2021
Comprehensive Formulary (PDF)	English Last Updated: 10/25/2022
Annual Notice of Change	English Last Updated: 8/27/2021
Find a Doctor, Hospital, and Pharmacy	English
Request for PHI Form	English
Transition of Care	English

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