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FirstMedicare Direct PPO Plus (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for FirstMedicare Direct PPO Plus (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on FirstMedicare Direct PPO Plus (PPO) in 2025, please refer to our full plan details page.
FirstMedicare Direct PPO Plus (PPO) is a PPO plan offered by The Carle Foundation available for enrollment in 2025 to people living in Sandhills. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that FirstMedicare Direct PPO Plus (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about FirstMedicare Direct PPO Plus (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For FirstMedicare Direct PPO Plus (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $63.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $6200.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $6200.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The FirstMedicare Direct PPO Plus (PPO) plan has an enhanced alternative drug benefit. The plan has no deductible. During the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, you'll pay a $15 copay for preferred generic drugs at a standard or mail pharmacy. After your yearly out-of-pocket drug costs reach $2000, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The FirstMedicare Direct PPO Plus (PPO) plan offers comprehensive coverage, including inpatient and outpatient hospital care, with varying copays. You'll find coverage for emergency services, primary care, and specialist visits, along with preventive, hearing, vision, and dental services. This plan also includes benefits for ambulance services, home health, and skilled nursing facilities, with specific copays and coinsurance amounts depending on the service. Additional services like acupuncture and meal benefits are available, while some services like cardiac rehabilitation and certain diagnostic tests are not covered.
Inpatient Hospital See details
The FirstMedicare Direct PPO Plus (PPO) plan covers inpatient hospital stays, including services not usually covered by Medicare, and requires prior authorization. For Inpatient Hospital-Acute, you will pay a $300 copay for days 1-10, and no copay for days 11-90. Inpatient Hospital Psychiatric has a $160 copay for days 1-10, and no copay for days 11-60. Additional Days for Inpatient Hospital-Acute and Non-Medicare-covered Stay for Inpatient Hospital-Acute are covered, but Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $275, observation services, and ambulatory surgical center services with no copay. Outpatient substance abuse services are covered, with individual and group sessions both having a copay of $25. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the FirstMedicare Direct PPO Plus (PPO) plan, but requires prior authorization. You will have a $45 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the FirstMedicare Direct PPO Plus (PPO) plan. Ground Ambulance Services have a $350 copay, and Air Ambulance Services have a $400 copay, but there is no coinsurance for either. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the FirstMedicare Direct PPO Plus (PPO) plan. Emergency Services has a $140 copay, Urgently Needed Services has a $15 copay, Worldwide Emergency Coverage has a $140 copay, Worldwide Urgent Coverage has a $15 copay, and Worldwide Emergency Transportation has a copay between $350 and $400.
Primary Care See details
The FirstMedicare Direct PPO Plus (PPO) plan covers primary care physician services with a $10 copay and chiropractic services with a $20 copay, but routine chiropractic care is not covered. Occupational therapy services have a $30 copay, and specialist services have a $25 copay. Mental health and psychiatric services have a $25 copay for individual and group sessions, and physical therapy and speech-language pathology services have a $30 copay. Additional telehealth benefits have a copay between $0 and $25, and Opioid Treatment Program Services have a $25 copay.
Preventive Services See details
The FirstMedicare Direct PPO Plus (PPO) plan covers preventive services, including annual physical exams, and additional services like fitness benefits up to $360 per year, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. Health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and other services are not covered.
Hearing Services See details
Hearing services in the FirstMedicare Direct PPO Plus (PPO) plan include routine hearing exams with a $25 copay, and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a copay between $495 and $1695, while prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
The FirstMedicare Direct PPO Plus (PPO) plan covers vision services, including routine eye exams with no deductible. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are covered, but there is a 20% coinsurance for contact lenses, with a combined maximum plan benefit of $130 every year.
Dental Services See details
Dental Services has a $3,000 annual maximum benefit for both in-network and out-of-network services, and covers Medicare Dental Services with a $25 copay. Other covered dental services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), restorative services with 15% coinsurance, adjunctive general services with 15% coinsurance, endodontics with 15% coinsurance, periodontics with 15% coinsurance, prosthodontics (removable) with 40% coinsurance, maxillofacial prosthetics with 40% coinsurance, implant services with 40% coinsurance, prosthodontics (fixed) with 40% coinsurance, and oral and maxillofacial surgery with 15% coinsurance; however, fluoride treatment and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the FirstMedicare Direct PPO Plus (PPO) plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits are covered under the FirstMedicare Direct PPO Plus (PPO) plan. Durable Medical Equipment (DME) has no copay and a coinsurance between 0% and 20%, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have no copay, but have a 20% coinsurance. Diabetic Supplies have no copay and a coinsurance between 0% and 20%, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance, and both require prior authorization.
Diagnostic and Radiological Services See details
The FirstMedicare Direct PPO Plus (PPO) plan covers diagnostic and radiological services, but Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered. Diagnostic Radiological Services have a copay of at most $250.00, while Therapeutic Radiological Services have a copay of at most $60.00.
Home Health Services See details
Home Health Services are covered by the FirstMedicare Direct PPO Plus (PPO) plan with no copay and no coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the FirstMedicare Direct PPO Plus (PPO) plan. Specifically, Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, with a copay of $10 for days 1-20 and $214 for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Under the "Other Services" benefit, this plan covers acupuncture with a $25 copay per visit, up to 15 treatments per year. Meal benefits are also covered, offering meals for chronic illnesses or medical conditions requiring home care. However, over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, EPSDT services, and several other services are not covered.
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