Medicare Prescription Drug Benefits (Part D)

Our Part D Benefit

FirstCare Advantage Dual SNP (HMO SNP) is pleased to offer Medicare Part D prescription drug benefit. When you enroll in FirstCare Advantage Dual SNP, you have the option to choose medical-only benefits, or medical benefits plus prescription drug coverage for one cost-effective premium. And no matter which plan you choose, you will still have coverage for Medicare Part B drugs.

FirstCare has a "closed" formulary, which means that drugs that are within a given therapeutic class are covered as allowed under the Medicare Part D prescription drug program. A "closed" formulary also limits the number of eligible Part D medications that will be reimbursed by the plan.

We also cover the drugs that are part of the Medicare Part B benefit, including most injectable drugs administered by a physician. The amounts you pay for those drugs do not count toward the Part D deductibles or out-of-pocket amounts.

Our Pharmacy Network

FirstCare Advantage Dual SNP has contracted with thousands of pharmacies across the country and meets or exceeds CMS requirements for pharmacy access in your area. You can use any pharmacy in our network. The pharmacies in our network can change at any time. See our online Provider/Pharmacy Directory, or for the most current information, check with Customer Service.

If you go to a pharmacy that is not in our network, you might have to pay more for your prescriptions. You also might have to follow special rules before getting your prescription in order for the prescription to be covered under our plan. For more information, call Customer Service.

Retail (30-day supply)
Generic	Low Income Subsidy: $0/$1.30/$3.60/15%
Brand	Low Income Subsidy: $0/$3.90/$8.95/15%
Mail Order (30-day supply)
Generic	Low Income Subsidy: $0/$1.30/$3.60/15%
Brand	Low Income Subsidy: $0/$3.90/$8.95/15%
Mail Order (90-day supply)
Generic	Low Income Subsidy: $0/$1.30/$3.60/15%
Brand	Low Income Subsidy: $0/$3.90/$8.95/15%
Coverage Gap	Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020. After you enter the coverage gap, you pay 25% of the plan's cost for covered brand name drugs and 25% of the plan's cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.
Catastrophic Coverage	After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,100, you pay the greater of: 5% of the cost, or $3.60 copay for generic (including brand drugs treated as generic)and $8.95 copayment for all other drugs

If you do not have Low-Income Subsidy, you will have an initial deductible of $435.00 for 2020. You will also have cost-sharing for generic and brand drugs at 25% coinsurance. When your total drug spend is $4,020 you will enter the Coverage Gap. You will then have cost-sharing of 25% of the cost for generic drugs and 25% of the cost for brand drugs. You will stay in the Coverage Gap until your out-of-pocket costs reach $6,350. Then you will enter the Catastrophic Coverage phase.

Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350, you generally pay nothing for all drugs.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year.

Part D Resources

2020
Low Income Subsidy Chart
Low Income Subsidy Chart - Version en Español

2019
Low Income Subsidy Chart
Low Income Subsidy Chart - Version en Español

Best Available Evidence

CMS Best Available Evidence (BAE) Policy

Medication Therapy Mangement (MTM) Program

H5742_WEBSITE_2020_A | Last updated: 10/01/19.

Resources

Access a Doctor, 24/7/365

FirstCare Virtual Care—powered by MDLIVE lets you connect with a doctor from wherever you are. For more details, click here.

Talk to a Nurse—Nurse24™

Need care advice? Should you see a doctor? Get the info you need today! FirstCare members can talk to a nurse 24/7 by calling 1-855-828-1013 to get answers 24 hours a day, 7 days a week! TTY users can call 7-1-1 or 1-800-955-8771. Voice communication is available at 1-800-955-8770.

Utilization Management

Ever wonder how we decide what services to authorize? Our utilization management (UM) decisions are based on medical evidence and consensus of health care professionals. For more details, click here.

How to Learn More

Schedule a sit-down:
Feel free to contact us, and a FirstCare Advantage Dual SNP (HMO SNP) representative will gladly sit down with you and compare the plans in greater detail.

Call us at:
1-866-229-4969
We are available;
October 1- March 31, 8 a.m. to 8 p.m. Central Time (CT) daily;
April 1- September 30, 8 a.m. to 8 p.m. Central Time (CT) Monday through Friday.

For TTY or for accommodation of persons with special needs, please call TTY 7-1-1.

Or, write:
FirstCare Advantage Dual SNP (HMO SNP)
Attn: Customer Service
1901 West Loop 289, Suite 9
Lubbock, TX 79407

"What's Covered" App
Centers for Medicare & Medicaid Services (CMS) has an app that gives you access to content about original Medicare. For more information, click here.

Medicare D-SNP
FirstCare Advantage Dual SNP (HMO SNP)