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FHCP Medicare Advantage

FHCP Medicare Valor (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	$30 copay
Inpatient Hospital Care	$320 copay per day for days 1-6 $0 copay per day for days 7-90 $0 copay per day for days 91 and beyond
Emergency Services (In and out-of-network)	$90 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 - $30 copay, depending on the service

Prescription Drug Coverage

Prescription Drug Deductible	N/A
In-Network Prescription Drug Coverage - Initial Coverage	N/A
Coverage Gap	N/A
Catastrophic Coverage	N/A

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

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	N/A

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
Find a Doctor, Hospital, and Pharmacy	English
Request for PHI Form	English
Transition of Care	English

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