FirstMedicare Direct  
 

 

Drug Benefit Frequently Asked Questions


What is a formulary?
A formulary is a list of covered drugs selected by FirstMedicare Direct in consultation with a team of healthcare providers. The formulary represents the prescription  therapies believed to be a necessary part of a quality treatment program. FirstMedicare Direct will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a FirstMedicare Direct network pharmacy and other plan rules are followed.

FirstMedicare Direct covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient as brand name drugs. Generic drugs usually cost less that brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

Note: Brand name drugs listed in parentheses within the Comprehensive Formulary are provided for informational purposes only. They do not indicate coverage. Use this section as a reference tool to assist you in identifying if a particular drug is on the formulary. Formulary brand name drugs are indicated in all capital letters while those drugs in lower case with the brand name in parentheses indicate that only the generic is on formulary. If you need assistance finding a drug, call Member Services at 1 (844) 201-4957 (TTY 711, select "Member Prescription Drug Option").

 

2020 Over the Counter Benefit Catalog Adobe PDF

2019 Over the Counter Benefit Catalog Adobe PDF

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Can the formulary change?
Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. 

During the year, FirstMedicare Direct may remove drugs from our formulary (list of covered drugs) or add rules about whether and when certain drugs are covered. We notify members of changes to the formulary at least 30 days before the change becomes effective by including Formulary Change notices in the monthly Part D Explanation of Benefits, or at the time you request a refill, at which time you will receive a 30-day supply of the medication. Effective January 1, 2020 when a new generic drug replaces a brand name drug on the Formulary (Drug List), or we change cost-sharing tier or add new restrictions to the brand name drug, we may immediately make this type of change without advance notice. To view available Formulary Change Notices, click here.

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What is the Transition Process?
FirstMedicare Direct has a transition process that will give you time to work with your health care provider to switch to a therapeutically equivalent prescription drug on our Formulary or to complete the Formulary Exceptions process. Click on the link below for more details and to see if you may be eligible. 

FirstMedicare Direct Transition Process

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Where can I fill my prescriptions?
FirstMedicare Direct has a large network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time.

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How can I get Extra Help with my prescription drug plan costs or other Medicare costs?
You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs.

To see if you qualify for getting extra help, call:

1 (800) MEDICARE or (1-800-633-4227).TTY/TDD users should call 1 (877) 486-2048,
24 hours a day/7 days a week and see www.medicare.gov 'Programs for People with Limited Income and Resources' in the publication Medicare & You.
The Social Security Administration at 1 (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1 (800) 325-0778, or
Your State Medicaid Office

Best Available Evidence Policy (www.cms.gov)

Low Income Subsidy Premium Summaries
2020 HMO Plus LIS Premium Summary Adobe PDF
2020 HMO Standard LIS Premium Summary Adobe PDF
2020 PPO Plus LIS Premium Summary Adobe PDF
2020 PPO Premier LIS Premium Summary Adobe PDF
2020 HMO Plus LIS Premium Summary Adobe PDF
2020 HMO Prime LIS Premium Summary Adobe PDF
2020 smartHMO LIS Premium Summary Adobe PDF
2020 HMO Plus LIS Premium Summary Adobe PDF
2020 HMO Standard LIS Premium Summary Adobe PDF


2019 HMO Plus LIS Premium Summary Adobe PDF
2019 HMO Standard LIS Premium Summary Adobe PDF
2019 PPO Plus LIS Premium Summary Adobe PDF
2019 Healthy State HMO Plus LIS Premium Summary Adobe PDF
2019 Healthy State HMO Prime LIS Premium Summary Adobe PDF
2019 smartHMO LIS Premium Summary Adobe PDF
2019 preferredPLUS (HMO) LIS Premium Summary Adobe PDF

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FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO plans with a Medicare contract. Enrollment in a FirstMedicare Direct plan depends on contract renewal.This is a required statement by CMS. FirstCarolinaCare has filed and been approved to offer an HMO and a PPO Medicare Advantage Prescription Drug plan for 2020.

 
Y0094_20042M_Accepted_10/01/2019

Page Last Updated:
Friday, October 2, 2020 11:13:09 AM