FirstMedicare Direct PPO Plus (PPO)
FirstMedicare Direct PPO Plus (PPO) H8064-002 Plan Details
FirstMedicare Direct PPO Plus (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by The Carle Foundation
Plan ID: H8064-002
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$41.40
Monthly Premium
FirstMedicare Direct PPO Plus (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by The Carle Foundation
Plan ID: H8064-002
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $3900 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $10.00 Out-of-Network: Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 20% |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $25.00 Out-of-Network: Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 20% |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $310.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Coinsurance for Acute Hospital Services per Stay 20% |
| Urgent Care | Copayment for Urgent Care $15.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $15.00 Maximum Plan Benefit of $10,000 |
| Emergency Room Visit | Copayment for Emergency Care $120.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 48 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120.00 Copayment for Worldwide Emergency Transportation $350.00 to $400.00 Maximum Plan Benefit of $10,000 |
| Ambulance Transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $350.00 to $400.00 Copayment for Medicare Covered Ambulance Services - Air $350.00 to $400.00 |
Health Care Services and Medical Supplies
FirstMedicare Direct PPO Plus (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $20.00 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Chiropractic Services 20% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Coinsurance for Medicare-covered Diabetic Supplies 0% to 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $250.00 Copayment for Medicare-covered Therapeutic Radiological Services $60.00 Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30% Coinsurance for Medicare Covered Lab Services 30% Coinsurance for Medicare Covered Diagnostic Radiological Services 30% Coinsurance for Medicare Covered Therapeutic Radiological Services 30% Coinsurance for Medicare Covered Outpatient X-Ray Services 30% |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Please see Evidence of Coverage for Additional Home Health Benefits Out-of-Network: Coinsurance for Medicare Covered Home Health 15% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $160.00 per day for days 1 to 10 $0.00 per day for days 11 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 20% |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $25.00 Copayment for Medicare-covered Group Sessions $25.00 Out-of-Network: Coinsurance for Medicare Covered Individual Sessions 20% Coinsurance for Medicare Covered Group Sessions 20% |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $275.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $275.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 20% |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $25.00 Copayment for Medicare-covered Group Sessions $25.00 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $25.00 Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 20% |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $203.00 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: Coinsurance for Skilled Nursing Facility Services per Stay 20% |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $25.00 Maximum Plan Allowance of $1500.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 20% Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 0% to 40% Coinsurance for Non-Medicare Covered Comprehensive Dental 0% to 40% Deductible $50.00 |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Eye Exams $0.00
Eyewear: Coinsurance for Medicare-Covered Benefits 20% Maximum Plan Allowance of $130.00 every year for all Non-Medicare covered eyewear for in and out of network services combined Out-of-Network: Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $0.00 Copayment for Non-Medicare Covered Eyewear $0.00 |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $25.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $495.00 to $1695.00
Out-of-Network: Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $0.00 Copayment for Non-Medicare Covered Hearing Aids $495.00 to $1695.00 |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
