FirstMedicare Direct PPO Plus (PPO)
North Carolina Medicare Advantage Plan (2025 Plan)
Additional Coverage
HearingVisionDental
Overall Government Star Rating
(coming soon)
Plan Name
FirstMedicare Direct PPO Plus (PPO)
Plan Type
Medicare Advantage Plan With Part D Prescription Drug Coverage
FirstMedicare Direct PPO Plus (PPO) is a Medicare Advantage Plan With Part D Prescription Drug Coverage, which is available in North Carolina and offered by the health insurance company FirstMedicare Direct. This plan’s network type is PPO which determines in-network doctors who accept the health plan and whether a referral is needed.
Primary doctor visit
$10 copay per visit
Specialist visit
$25 copay per visit
ER visit
$140 copay per visit (always covered)
FirstMedicare Direct PPO Plus (PPO) has a monthly premium cost of $63 per month, with an annual deductible of $0 and a maximum out of pocket cost sharing of $6,200 In and Out-of-network
$3,900 In-network. The most common benefit costs which people evaluate when choosing a plan are costs for a primary doctor visit, specialist doctor visit, emergency room visit, and ambulance. These costs are listed in this summary section and a full list of benefit costs for FirstMedicare Direct PPO Plus (PPO) are defined below.
Yes
Part D Prescription Drug Coverage
FirstMedicare Direct PPO Plus (PPO) is a Medicare Advantage plan which does include Medicare Part D Prescription Drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. FirstMedicare Direct PPO Plus (PPO) includes coverage for hearing, vision, dental.
Medicare Advantage health plans can offer even more additional benefits. FirstMedicare Direct PPO Plus (PPO) includes coverage for the following additional benefits:
Other benefits
Over the counter drug benefits
Home and bathroom safety devices
Health Portion of Premium
Health Plan Max Out-of-Pocket
$6,200 In and Out-of-network
$3,900 In-network
Nationwide Coverage included
Hearing Coverage included
Doctor Services
Primary doctor visit
In-network: $10 copay per visit
Out-of-network: 20% coinsurance per visit
Specialist visit
In-network: $25 copay per visit
Out-of-network: 20% coinsurance per visit
Tests, labs, & imaging
Diagnostic tests & procedures
In-network: $0 copay
Out-of-network: 30% coinsurance
Lab services
In-network: $0 copay
Out-of-network: 30% coinsurance
Diagnostic radiology services (like MRI)
In-network: $250 copay
Out-of-network: 30% coinsurance
Outpatient x-rays
In-network: $0 copay
Out-of-network: 30% coinsurance
Emergency care
$140 copay per visit (always covered)
Urgent care
$15 copay per visit (always covered)
Hospital Services
Inpatient hospital coverage
In-network: $300 per day for days 1 through 10
$0 per day for days 11 through 90
Out-of-network: 20% per stay
Outpatient hospital coverage
In-network: $0-275 copay per visit
Out-of-network: 20% coinsurance per visit
Skilled nursing facility
Skilled nursing facility
In-network: $10 per day for days 1 through 20
$214 per day for days 21 through 100
Out-of-network: 20% per stay
Preventive services
Preventive services
In-network: $0 copay
Out-of-network: $0 copay
Ambulance
Ground ambulance
In-network: $350 copay
Out-of-network: $350-400 copay
Therapy services
Occupational therapy visit
In-network: $30 copay
Out-of-network: 20% coinsurance
Physical therapy & speech & language therapy visit
In-network: $30 copay
Out-of-network: 20% coinsurance
Mental health services
Outpatient group therapy with a psychiatrist
In-network: $25 copay
Out-of-network: 20% coinsurance
Outpatient individual therapy with a psychiatrist
In-network: $25 copay
Out-of-network: 20% coinsurance
Outpatient group therapy visit
In-network: $25 copay
Out-of-network: 20% coinsurance
Outpatient individual therapy visit
In-network: $25 copay
Out-of-network: 20% coinsurance
Opioid treatment services
Opioid treatment services
Other services
Durable medical equipment (like wheelchairs & oxygen)
In-network: 0-20% coinsurance per item
Out-of-network: 20% coinsurance per item
Prosthetics (like braces, artificial limbs)
In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
Diabetes supplies
In-network: 0-20% coinsurance per item
Out-of-network: 20% coinsurance per item
Tier drug costs for: Standard retail pharmacy drug cost for 1-month
| Tiers | Initial coverage phase | Catastrophic coverage phase |
|---|
| Preferred Generic | $2.00 copay | $0 copay |
| Generic | $15.00 copay | $0 copay |
| Preferred Brand | 25% coinsurance | $0 copay |
| Non-Preferred Drug | 50% coinsurance | $0 copay |
| Specialty Tier | 33% coinsurance | $0 copay |
Part B Drugs
Chemotherapy drugs
In-network: 0-20% coinsurance
Out-of-network: 20% coinsurance
Other Part B drugs
In-network: 0-20% coinsurance
Out-of-network: 20% coinsurance
Hearing
Hearing exam
In-network: $25 copay
Out-of-network: 20% coinsurance
Fitting/evaluation
In-network: $0 copay
Out-of-network: $0 copay
Hearing aids - All types
In-network: $495-1,695 copay
Out-of-network: $495-1,695 copay
Preventive Dental
Oral exam
In-network: $0 copay
Out-of-network: 0%-40% coinsurance
Cleaning
In-network: $0 copay
Out-of-network: 0%-40% coinsurance
Dental x-rays
In-network: $0 copay
Out-of-network: 0%-40% coinsurance
Comprehensive dental
Restorative services
In-network: 15% coinsurance
Out-of-network: 0%-40% coinsurance
Endodontics
In-network: 15% coinsurance
Out-of-network: 0%-40% coinsurance
Periodontics
In-network: 15% coinsurance
Out-of-network: 0%-40% coinsurance
Prosthodontics, removable
In-network: 40% coinsurance
Out-of-network: 0%-40% coinsurance
Prosthodontics, fixed
In-network: 40% coinsurance
Out-of-network: 0%-40% coinsurance
Maxillofacial prosthetics
In-network: 40% coinsurance
Out-of-network: 0%-40% coinsurance
Implant services
In-network: 40% coinsurance
Out-of-network: 0%-40% coinsurance
Oral and maxillofacial surgery
In-network: 15% coinsurance
Out-of-network: 0%-40% coinsurance
Adjunctive general services
In-network: 15% coinsurance
Out-of-network: 0%-40% coinsurance
Vision
Routine eye exam
In-network: $0 copay
Out-of-network: $0 copay
Contact lenses
In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses (frames & lenses)
In-network: $0 copay
Out-of-network: $0 copay
Eyeglass frames (only)
In-network: $0 copay
Out-of-network: $0 copay
Eyeglass lenses (only)
In-network: $0 copay
Out-of-network: $0 copay
Upgrades
In-network: $0 copay
Out-of-network: $0 copay
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