FirstMedicare Direct PPO Plus (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from FirstMedicare Direct PPO Plus (PPO) by Firstcarolinacare Insurance Company. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a North Carolina Medicare Part-C plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This FirstMedicare Direct PPO Plus (PPO)(H8064-002) plan has a $0 drug deductible. The Initial Coverage Limit (ICL) for this plan is $4660. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Firstcarolinacare Insurance Company will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link above the chart.



Plan Overview

Plan Name:FirstMedicare Direct PPO Plus (PPO)
Plan ID: H8064-002
Provider: Firstcarolinacare Insurance Company
Plan Year:2023
Premium:$38.50
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:North Carolina
Similar Plan:H8064-002


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
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Drug
Name⇅
Tier
Level
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Famciclovir
2NA$15NANN
Famotidine
2NA$15NANN
Fanapt
4NA45%NANY
Febuxostat
2NA$15NANN
Felbamate
2NA$15NANN
Felodipine
2NA$15NANN
Femring
4NA45%NANN
Femynor
2NA$15NANN
Fenofibrate
2NA$15NANN
Fenoprofen Calcium
1NA$2NANN
Fentanyl
2NA$15NA10/30NN
Fentanyl Citrate
5NA33%NA120/30YN
Fentanyl Transdermal
2NA$15NA10/30NN
Ferriprox
5NA33%NANN
Fetzima
4NA45%NANY
Finacea Foam
4NA45%NANN
Firmagon
5NA33%NANN
Flac Otic Oil
2NA$15NANN
Flavoxate Hydrochloride
1NA$2NANN
Flebogamma Dif
5NA33%NAYN
Flecainide Acetate
2NA$15NANN
Flovent
4NA45%NA24/30NY
Fluconazole
2NA$15NANN
Flucytosine
5NA33%NANN
Fludrocortisone Acetate
1NA$2NANN
Flunisolide
1NA$2NANN
Fluocinolone Acetonide
2NA$15NANN
Fluocinonide
4NA45%NANN
Fluorometholone
2NA$15NANN
Fluorouracil
2NA$15NANN
Fluorouracil Cream
5NA33%NANN
Fluoxetine
1NA$2NANN
Fluoxetine Hydrochloride
4NA45%NANN
Fluphenazine Decanoate
2NA$15NANN
Fluphenazine Hydrochloride
2NA$15NANN
Flurandrenolide
4NA45%NANN
Flurazepam Hydrochloride
2NA$15NA30/30NN
Flurbiprofen
1NA$2NANN
Flurbiprofen Sodium
1NA$2NANN
Fluticasone Propionate
1NA$2NANN
Fluticasone Propionate And Salmeterol
2NA$15NANN
Fluvoxamine Maleate
1NA$2NANN
Fondaparinux Sodium
5NA33%NANN
Forfivo
4NA45%NANY
Forteo
5NA33%NAYN
Fosamprenavir Calcium
5NA33%NANN
Fosfomycin Tromethamine
2NA$15NANN
Fosinopril Sodium
1NA$2NANN
Fosinopril Sodium And Hydrochlorothiazide
2NA$15NANN
Fosrenol
5NA33%NANN
Fotivda
5NA33%NAYN
Fragmin
5NA33%NANN
Furosemide
1NA$2NANN
Fuzeon
5NA33%NANN
Fycompa
5NA33%NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H8064-002

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $0. Some plans offer select Pre-deductible drug Coverage
2. Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2023 is $505. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Preferred: Your Cost for the Drug at the Providers In-Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non-Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plan's formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Last updated on

Source:CMS Formulary Data Q4 2022
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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