FHCP Medicare Advantage
FHCP Medicare Premier Advantage (HMO)
FHCP Medicare Advantage
FHCP Medicare Rx Plus (HMO-POS)
FHCP Medicare Advantage
FHCP Medicare Rx Plus POS (HMO-POS)
Coverage Summary
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Is My Doctor In-Network? Is My Doctor In-Network? |
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Primary Care Doctor Visit The Primary Care Doctor you choose will focus on your needs and coordinate your care with other network providers. |
$0 copay |
$0 copay |
In-Network: $0 copay |
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Specialist Visit Care you receive from a doctor who specializes in a certain type of medicine. Certain specialists do not require a Primary Care Doctor referral. Ask your Primary Care Doctor if you need a referral. |
$15 copay |
$20 copay |
In-Network: $20 copay |
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Inpatient Hospital Care Prior Authorization is required for non-emergency Inpatient Hospital stays. |
$215 copay per day for days 1-5 |
$300 copay per day for days 1-6 |
In-Network: |
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Emergency Services (In and out-of-network) Services received at a hospital facility's Emergency department, including both Professional and Facility services. |
$125 copay, waived if admitted within 24 hours for the same condition. |
$100 copay, waived if admitted within 24 hours for the same condition. |
In- and Out-of-Network |
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Urgent Care Services Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical attention. |
$0 - $10 copay, depending on the service |
$0 - $20 copay, depending on the service |
In- and Out-of-Network |
Prescription Drug Coverage
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Prescription Drug Deductible The amount you must pay before our plan begins to pay its share of your covered drugs. |
$0 |
$0 |
$0 |
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In-Network Prescription Drug Coverage - Initial Coverage During the initial coverage stage, your plan helps cover the costs of your prescription drugs. How much you pay depends on which plan you have, what tier your prescription is in, and where and how you fill your prescription. Check your plan’s Evidence of Coverage for more details about what you pay. |
Tier 1 - Preferred Generic |
Tier 1 - Preferred Generic |
Tier 1 - Preferred Generic |
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Coverage Gap In the coverage gap, you may pay more for your drugs than you did in the initial coverage stage. That’s why it’s called a “gap”. You stay in the coverage gap until your total out-of-pocket drug costs reach the Initial Coverage Limit. |
For Generic drugs, you pay: |
For Generic drugs, you pay: |
For Generic drugs, you pay: |
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Catastrophic Coverage Once you reach the Catastrophic Stage, you pay a small copay and the plan will pay most of the cost of your drugs for the rest of the year. |
$0 copay |
$0 Copay |
$0 Copay |
Extra Coverage
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Extra Benefits Enjoy some of these extra benefits included in your plan |
Routine vision |
Routine Vision |
Routine Vision |
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Out of Network Coverage
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Medical Services/Supplies 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. |
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. |
If you receive care from an out-of-network provider, your out-of-pocket costs will usually be higher than if you use a network provider. There are three exceptions: emergency care, urgently needed care and dialysis services. For details about the plan's coverage of out-of-network care, please refer to the Summary of Benefits or the Evidence of Coverage. (See "Plan Documents" below.) |
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Prescription Drugs 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. |
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. |
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) |
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| Evidence of Coverage (PDF) |
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| Plan Rating (PDF) |
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| General Transition Notice (PDF) |
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| Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) |
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| Comprehensive Formulary (PDF) |
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| Annual Notice of Change |
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| Find a Doctor, Hospital, and Pharmacy | |||
| Request for PHI Form | |||
| Transition of Care | |||
| Enrollment Form |
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