Pre-Enrollment Book 2013 FirstMedicare Direct PPO Plus (PPO

Transcription

Pre-Enrollment Book 2013
FirstMedicare Direct PPO Plus (PPO)
Service Area – Hoke, Lee, Montgomery, Moore, Richmond, Scotland
Counties
H8064_13_03 CMS Approved 10102012
Dear Medicare Beneficiary:
As per your request, enclosed you will find information about our plans and all the
materials you need to enroll. We have enclosed a postage paid envelope to facilitate
your enrollment.
If you choose to enroll, you will first receive your id card with a confirmation of
Enrollment letter, followed by your New Member Welcome kit. The kit will include
materials about the plan you enrolled in consisting of but not limited to the Evidence of
Coverage, Provider and Pharmacy Directory and Formulary.
Members may enroll in the plan only during specific times of the year. Benefits and costsharing may change from year to year. Should you have any questions or need further
assistance with completing the enrollment form or choosing a primary care physician,
please do not hesitate to call us at 1-877-279-1732, (TTY 711) for the hearing
impaired). We are available to take your call from 8:00am to 8:00pm 7 days a week.
You can also visit us online at www.firstmedicare.com
People with limited incomes may qualify for Extra Help to pay for their prescription drug
costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of
your drug costs including monthly prescription drug premiums, annual deductibles, and
co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a
late enrollment penalty. Many people are eligible for these savings and don’t know it. For
more information about this Extra Help, contact your local Social Security office or call
1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users
should call 1-877-486-2048.
The information in this booklet will help you explore the benefits of becoming a
FirstMedicare Direct Member. As a guide we encourage you to review the Summary of
Benefits as it provides detailed coverage that our plans offer. Our representatives will be
happy to answer any questions you may have. No question is too big or small. Please
don’t hesitate to call 1-877-279-1732.
We are very excited about offering a Medicare Advantage product to our communities,
and we look forward to serving you.
Sincerely,
Kenneth Lewis
President
FirstCarolinaCare Insurance Company
FirstMedicare Direct has plan options that may benefit you
Thank you for your interest in FirstMedicare Direct plans. It’s important to understand
what options are available to you as a Medicare beneficiary. We encourage you to take
the time to review this enrollment kit and use it to help you make the best choice for
your Medicare coverage.
Inside this kit, you’ll find all the materials you need to help you make a decision about
your health care coverage.

•
•
•
•
•
Plan Comparison Tool
Summary of Benefits — includes details about our HMO and PPO plans
Enrollment Application — apply for enrollment in the FirstMedicare Direct plan of
your choice
Payment Election Form — this form allows you to select a safe and easy electronic
way to pay for your health care coverage
Abridged Formulary — use this booklet to help you find out which prescription
drugs are covered by the FirstMedicare Direct plan
Provider Directory — locate providers and specialists who are participating in the
FirstMedicare Direct network
If you have questions or need help applying for enrollment, please call us toll-free at 1877-279-1732 from 8 a.m. to 8 p.m., seven days a week. TTY/TDD users, call 711.
Have questions?
Need help with enrolling?
If you have questions about the information provided in this kit or about Medicare in
general, we have knowledgeable, licensed sales representatives who can get you the
answers you need and help you to apply for enrollment in a FirstMedicare Direct plan.
Toll-Free: 1-877-279-1732
(TTY 711)
8 a.m. to 8 p.m., seven days a week
www.firstmedicare.com
42 Memorial Drive
Pinehurst, NC 28734
Important questions to help you identify which plan is best for you
How do the FirstMedicare Direct plans compare to my current plan?
Answer:
What premium best meets your needs?
Answer:
Do you want a plan that includes both medical and prescription drug coverage?
Answer:
Can I get all of my services within the FirstMedicare Direct Network?
Answer:
Is my Hospital in the network?
Answer:
Is my Primary Care physician in the network?
Answer:
Are my specialists in the network?
Answer:
Are my drugs on the Formulary Drug list?
Answer:
What tier are my Drugs in and what are their copays?
Answer:
Do I understand the 3 stages of prescription Drug Coverage?
Answer:
Do I understand my rights and protections as a Medicare Beneficiary?
Answer:
Am I eligible for Extra Help?
Answer:
Do I understand Plan Ratings and where can I find this information?
Answer:
www.medicare.gov
Where can I research the answers to these questions?
Answer:
Use this enrollment kit.
Online at www.firstmedicare.com
Online at www.medicare.gov
What Additional Benefits does my plan include?
Membership at any FirstHealth Fitness Center
24 Hour Nurse Hotline
USE THIS TOOL TO COMPARE OUR PLANS TO YOURS
Benefits
HMO Plus
PPO Plus
In/Out Network
1.Plan Premium
$0
$49.90
Supplemental Plan Premium
$0
$0
Part D Prescription Drug
Premium
$0
$0
Total Annual Premium
$0
$598.80
2. Deductible
$0
$0
3. Doctor’s Visit – Primary
Care
$10
In/$15 Out/$20
4. Doctor’s Visit – Specialist
$35
In/$40 Out/$40
$195/day for
days 1-6
$0/day for days
7-90
In/$195/day
for days 1-6
Out/$250/day
for days 1-6
$0/day for days
7-90
$3,400
In Network $3,400/
Combined In
and Out of
Network $5,100
7. Emergency Room Visit
$50
$50
8. Urgent Care Center Visit
$35
$35
9. Freedom to use any
Medicare Approved Provider
No. You must
use
FirstMedicare
Direct Providers
(except for
emergencies)
Yes/Out-ofNetwork
benefits may
apply
Included
Included
$7
$7
Tier 1 Generics
Tier 1 Generics
5. Hospital Stays
6. Out-of-Pocket Maximum
10. FirstHealth Fitness
membership
11. Tier 1 (Preferred Generic)
(30-Day Supply)
12. Drugs in Coverage Gap?
Is my doctor In-Network?
Current Plan
Benefits
HMO Plus
PPO Plus
In/Out Network
Current Plan
My Physician
Are my specialist’s In-Network?
Specialist #1
Specialist #2
Specialist #3
How are my Drugs covered?
Drug #1 Copay
Drug #2 Copay
Drug #3 Copay
What are my annual copays, premiums and total cost?
Annual Physician Visits:
$10 Each
$15/$20 Each
Total:
_________
Total:
_________
$35 Each
$40/$40 Each
Total:
_________
Total:
_________
$195 Each
(Days 1-6)
Total:
_________
$195 Each
(Days 1-6)
Total:
_________
Fitness Center Costs
$0
$0
Annual Premium
$0
$598.80
# Primary Care Visits_____
#Specialist Care Visits
_____
Annual HospitalVisits
Estimated Days_____
Drug Copays
Copays (Total)
Grand Total
FirstCarolinaCare is a Health plan with a Medicare contract. 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 may change on January 1 of each year. You must continue to pay your
Medicare Part B premium.
NOTES
Multi-language Interpreter Services
English: We have free interpreter services to answer any questions you may have about our health or drug
plan. To get an interpreter, just call us at 1-877-279-1732 (TTY-711). Someone who speaks English/Language
can help you. This is a free service.
Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda
tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-877279-1732 (TTY-711). Alguien que hable español le podrá ayudar. Este es un servicio gratuito.
Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。如果您需
要此翻译服务，请致电1-877-279-1732(TTY-711)。我们的中文工作人员很乐意帮助您。这是一项免费服
务。
Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。如需翻
譯服務，請致電1-877-279-1732(TTY-711)。我們講中文的人員將樂意為您提供幫助。這是一項免費服
務。
Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan
ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan
lamang kami sa 1-877-279-1732 (TTY-711). Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito
ay libreng serbisyo.
French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives
à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit
de nous appeler au 1-877-279-1732 (TTY-711). Un interlocuteur parlant Français pourra vous aider. Ce service
est gratuit.
Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương
trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi [1-877-279-1732 (TTY-711). sẽ có nhân viên nói tiếng
Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí .
German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und
Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-877-279-1732 (TTY-711). Man wird Ihnen dort auf
Deutsch weiterhelfen. Dieser Service ist kostenlos.
Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고
있습니다. 통역 서비스를 이용하려면 전화1-877-279-1732(TTY-711) 번으로 문의해 주십시오. 한국어를
하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.
Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете
воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами
переводчика, позвоните нам по телефону 1-877-279-1732(TTY-711). Вам окажет помощь сотрудник,
который говорит по-pусски. Данная услуга бесплатная.
Arabic: ‫ ليس‬،‫ للحصول على مترجم فوري‬.‫إننا نقدم خدمات المترجم الفوري المجانية لإلجابة عن أي أسئلة تتعلق بالصحة أو جدول األدوية لدينا‬
‫ سيقوم شخص ما يتحدث العربية‬7-811-312-7123)TYY 177( ‫ هذه خدمة مجانية عليك سوى االتصال بنا على‬.‫بمساعدتك‬.
Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro
piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-877-279-1732 (TTY-711). Un nostro
incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.
Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha
acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número
1-877-279-1732 (TTY-711). Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é
gratuito.
French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal
oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-877-279-1732 (TTY-711). Yon moun ki pale
Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.
Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi
na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język
polski, należy zadzwonić pod numer 1-877-279-1732 (TTY-711). a usługa jest bezpłatna.
Hindi: हमारे स्वास््य या दवा की योजना के बारे में आपके ककसी भी प्रश्न के जवाब दे ने के लिए हमारे पास
मुफ्त दभ
ु ाषिया सेवाएँ उपिब्ध हैं. एक दभ
ु ाषिया प्राप्त करने के लिए, बस हमें 1-877-279-1732 (TTY-711). पर
फोन करें . कोई व्यक्तत जो हहन्दी बोिता है आपकी मदद कर सकता है . यह एक मुफ्त सेवा है .
Japanese: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために、無料の通
訳サービスがありますございます。通訳をご用命になるには、1-877-279-1732 (TTY-711) にお電話くだ
さい。日本語を話す人者が支援いたします。これは無料のサービスです。
2013
Summary of Benefits
Hoke, Lee, Montgomery, Moore, Richmond, Scotland Counties
H8064_13_07 CMS Accepted 09292012
Last Update 09012012
1 | FirstMedicare Direct PPO Plus (PPO) – Summary of Benefits
SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS
Thank you for your interest in FirstMedicare Direct PPO Plus (PPO). Our plan is offered by
FIRSTCAROLINACARE INSURANCE COMPANY, a Medicare Advantage Preferred Provider
Organization (PPO) that contracts with the Federal government. This Summary of Benefits tells you some
features of our plan. It doesn't list every service that we cover or list every limitation or exclusion. To get a
complete list of our benefits, please call FirstMedicare Direct PPO Plus (PPO) and ask for the "Evidence of
Coverage".
YOU HAVE CHOICES IN YOUR HEALTH CARE
As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (feefor-service) Medicare Plan. Another option is a Medicare health plan, like FirstMedicare Direct PPO Plus
(PPO). You may have other options too. You make the choice. No matter what you decide, you are still in
the Medicare Program.
You may be able to join or leave a plan only at certain times. Please call FirstMedicare Direct PPO Plus
(PPO) at the number listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more
information. TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a
week.
HOW CAN I COMPARE MY OPTIONS?
You can compare FirstMedicare Direct PPO Plus (PPO) and the Original Medicare Plan using this Summary
of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what
our plan covers and what the Original Medicare Plan covers.
Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits,
which may change from year to year.
WHERE IS FirstMedicare Direct PPO Plus (PPO) AVAILABLE?
The service area for this plan includes: Hoke, Lee, Montgomery, Moore, Richmond, Scotland Counties, NC.
You must live in one of these areas to join the plan.
WHO IS ELIGIBLE TO JOIN FirstMedicare Direct PPO Plus (PPO)?
You can join FirstMedicare Direct PPO Plus (PPO) if you are entitled to Medicare Part A and enrolled in
Medicare Part B and live in the service area. However, individuals with End-Stage Renal Disease are
generally not eligible to enroll in FirstMedicare Direct PPO Plus (PPO) unless they are members of our
organization and have been since their dialysis began.
CAN I CHOOSE MY DOCTORS?
FirstMedicare Direct PPO Plus (PPO) has formed a network of doctors, specialists, and hospitals. You can
use any doctor who is part of our network. You may also go to doctors outside of our network. The health
providers in our network can change at any time.
You can ask for a current provider directory. For an updated list, visit us at www.firstmedicare.com. Our
customer service number is listed at the end of this introduction.
WHAT HAPPENS IF I GO TO A DOCTOR WHO'S NOT IN YOUR NETWORK?
You can go to doctors, specialists, or hospitals in or out of network. You may have to pay more for the
services you receive outside the network, and you may have to follow special rules prior to getting services
in and/or out of network. For more information, please call the customer service number at the end of this
introduction.
WHERE CAN I GET MY PRESCRIPTIONS IF I JOIN THIS PLAN?
FirstMedicare Direct PPO Plus (PPO) has formed a 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. You can ask for a
pharmacy directory or visit us at www.firstmedicare.com. Our customer service number is listed at the end of
this introduction.
DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS?
FirstMedicare Direct PPO Plus (PPO) does cover both Medicare Part B prescription drugs and Medicare Part
D prescription drugs.
WHAT IS A PRESCRIPTION DRUG FORMULARY?
FirstMedicare Direct PPO Plus (PPO) uses a formulary. A formulary is a list of drugs covered by your plan
to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain
drugs or change how much you pay for a drug. If we make any formulary change that limits our members'
ability to fill their prescriptions, we will notify the affected members before the change is made. We will
send a formulary to you and you can see our complete formulary on our Web site at www.firstmedicare.com.
If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits,
you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch
to an alternative drug listed on our formulary with your physician's help. Call us to see if you can get a
temporary supply of the drug or for more details about our drug transition policy.
HOW CAN I GET EXTRA HELP WITH MY PRESCRIPTION DRUG PLAN COSTS OR GET
EXTRA HELP WITH 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 (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.
WHAT ARE MY PROTECTIONS IN THIS PLAN?
All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits
and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to
continue to participate with Medicare Advantage. A plan may continue in their entire service area
(geographic area where the plan accepts members) or choose to continue only in certain areas. Also,
Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the
program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar
year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your
options for Medicare coverage in your area.
As a member of FirstMedicare Direct PPO Plus (PPO), you have the right to request an organization
determination, which includes the right to file an appeal if we deny coverage for an item or service, and the
right to file a grievance. You have the right to request an organization determination if you want us to
provide or pay for an item or service that you believe should be covered. If we deny coverage for your
requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for
an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could
seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor
makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a
grievance with us if you have any type of problem with us or one of our network providers that does not
involve coverage for an item or service. If your problem involves quality of care, you also have the right to
file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the
Evidence of Coverage (EOC) for the QIO contact information.
As a member of FirstMedicare Direct PPO Plus (PPO), you have the right to request a coverage
determination, which includes the right to request an exception, the right to file an appeal if we deny
coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage
determination if you want us to cover a Part D drug that you believe should be covered. An exception is a
type of coverage determination. You may ask us for an exception if you believe you need a drug that is not
on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost.
You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you
think you need an exception, you should contact us before you try to fill your prescription at a pharmacy.
Your doctor must provide a statement to support your exception request. If we deny coverage for your
prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the
right to file a grievance if you have any type of problem with us or one of our network pharmacies that does
not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right
to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the
Evidence of Coverage (EOC) for the QIO contact information.
WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM?
A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited to
participate in a program designed for your specific health and pharmacy needs. You may decide not to
participate but it is recommended that you take full advantage of this covered service if you are selected.
Contact FirstMedicare Direct PPO Plus (PPO) for more details.
WHAT TYPES OF DRUGS MAY BE COVERED UNDER MEDICARE PART B?
Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not
limited to, the following types of drugs. Contact FirstMedicare Direct PPO Plus (PPO) for more details.
-- Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who
could be the patient) under doctor supervision.
-- Osteoporosis Drugs: Injectable osteoporosis drugs for some women.
-- Erythropoietin (Epoetin Alfa or Epogen®): By injection if you have end-stage renal disease (permanent
kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.
-- Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.
-- Injectable Drugs: Most injectable drugs administered incident to a physicians service.
-- Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant took
place in a Medicare-certified facility and was paid for by Medicare or by a private insurance company that
was the primary payer for Medicare Part A coverage.
-- Some Oral Cancer Drugs: If the same drug is available in injectable form.
-- Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.
-- Inhalation and Infusion Drugs administered through Durable Medical Equipment.
WHERE CAN I FIND INFORMATION ON PLAN RATINGS?
The Medicare program rates how well plans perform in different categories (for example, detecting and
preventing illness, ratings from patients and customer service). If you have access to the web, you may use
the web tools on www.medicare.gov and select "Health and Drug Plans" then "Compare Drug and Health
Plans" to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a
copy of the plan ratings for this plan. Our customer service number is listed below.
Please call FirstCarolinaCare Insurance Company for more information about FirstMedicare Direct PPO Plus
(PPO).
Visit us at www.firstmedicare.com or, call us:
Customer Service Hours for October 1 - February 14:
Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Eastern
Customer Service Hours for February 15 - September 30:
Monday, Tuesday, Wednesday, Thursday, Friday, 8:00 a.m. - 8:00 p.m. Eastern
Current and Prospective members should call toll-free (888)-350-7794 for questions related to the Medicare
Advantage Program. (TTY 711).
Current and Prospective members should call locally (888)-350-7794 for questions related to the Medicare
Advantage Program. (TTY 711).
Current and Prospective members should call toll-free (888)-350-7794 for questions related to the Medicare
Part D Prescription Drug program. (TTY 711).
Current and Prospective members should call locally (888)-350-7794 for questions related to the Medicare
Part D Prescription Drug program. (TTY 711)
For more information about Medicare, please call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY
users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.
Or, visit www.medicare.gov on the web.
This document may be available in other formats such as Braille, large print or other alternate formats.
This document may be available in a non-English language. For additional information, call customer service
at the phone number listed above.
If you have any questions about this plan's benefits or costs, please contact FirstCarolinaCare Insurance
Company for details.
SECTION II - SUMMARY OF BENEFITS
Benefit
Original Medicare
IMPORTANT INFORMATION
1 - Premium and
Other Important
Information
In 2012 the monthly Part B
premium was $99.90 and may
change for 2013 and the annual
Part B deductible amount was
$140 and may change for 2013.
General
$49.90 monthly plan premium in addition to your
monthly Medicare Part B premium.
Most people will pay the standard monthly Part B
premium in addition to their MA plan premium.
However, some people will pay higher Part B and
Part D premiums because of their yearly income
(over $85,000 for singles, $170,000 for married
If a doctor or supplier does not
couples). For more information about Part B and
accept assignment, their costs are Part D premiums based on income, call Medicare at
often higher, which means you
1-800-MEDICARE (1-800-633-4227). TTY users
pay more.
should call 1-877-486-2048. You may also call
Social Security at 1-800-772-1213. TTY users
should call 1-800-325-0778.
Some physicians, providers and suppliers that are
out of a plan's network (i.e., out-of-network) accept
"assignment" from Medicare and will only charge
Most people will pay the
up to a Medicare-approved amount. If you choose to
standard monthly Part B
premium. However, some people see an out-of-network physician who does NOT
accept Medicare "assignment," your coinsurance
will pay a higher premium
can be based on the Medicare-approved amount plus
because of their yearly income
an additional amount up to a higher Medicare
(over $85,000 for singles,
"limiting charge." If you are a member of a plan that
$170,000 for married couples).
For more information about Part charges a copay for out-of-network physician
services, the higher Medicare "limiting charge" does
B premiums based on income,
not apply. See the publications Medicare & You or
call Medicare at 1-800MEDICARE (1-800-633-4227). Your Medicare Benefits available on
www.medicare.gov for a full listing of benefits
TTY users should call 1-877under Original Medicare, as well as for explanations
486-2048. You may also call
of the rules related to "assignment" and "limiting
Social Security at 1-800-772charges" that apply by benefit type.
1213. TTY users should call 1800-325-0778.
To find out if physicians and DME suppliers accept
assignment or participate in Medicare, visit
www.medicare.gov/physician or
www.medicare.gov/supplier. You can also call 1800-MEDICARE, or ask your physician, provider,
or supplier if they accept assignment.
Benefit
Original Medicare
IMPORTANT INFORMATION
1 - Premium and
Other Important
Information
(continued)
In-Network
$3,400 out-of-pocket limit for Medicare-covered
services.
In and Out-of-Network
$5,100 out-of-pocket limit for Medicare-covered
services.
You may go to any doctor,
2 - Doctor and
specialist or hospital that accepts
Hospital Choice
(For more information, Medicare.
see Emergency Care #15 and Urgently
Needed Care - #16.)
In-Network
Referral required for network specialists (for certain
benefits).
You can go to doctors, specialists, and hospitals in
or out of the network. It will cost more to get out of
network benefits.
Out of Service Area
Plan covers you when you travel in the U.S. or its
territories.
SUMMARY OF BENEFITS
INPATIENT CARE
3 - Inpatient Hospital In 2012 the amounts for each
benefit period were:
Care
(includes Substance
Abuse and
Rehabilitation
Services)
In-Network
Plan covers 90 days each benefit period.
Days 1 - 60: $1156 deductible
For Medicare-covered hospital stays:
Days 61 - 90: $289 per day
Days 91 - 150: $578 per lifetime - Days 1 - 6: $195 copay per day
reserve day
- Days 7 - 90: $0 copay per day
These amounts may change for
2013.
Plan covers 60 lifetime reserve days. $0 copay per
lifetime reserve day.
Call 1-800-MEDICARE (1-800633-4227) for information about Out-of-Network
lifetime reserve days.
For hospital stays:
Lifetime reserve days can only
be used once.
A "benefit period" starts the day
you go into a hospital or skilled
nursing facility. It ends when
you go for 60 days in a row
without hospital or skilled
nursing care.
If you go into the hospital after
one benefit period has ended, a
new benefit period begins. You
must pay the inpatient hospital
deductible for each benefit
period. There is no limit to the
number of benefit periods you
can have.
Benefit
Original Medicare
INPATIENT CARE
4 - Inpatient Mental
Health Care
In 2012 the amounts for each
benefit period were:
In-Network
You get up to 190 days of inpatient psychiatric
hospital care in a lifetime. Inpatient psychiatric
Days 1 - 60: $1156 deductible
hospital services count toward the 190- day lifetime
Days 61 - 90: $289 per day
limitation only if certain conditions are met. This
Days 91 - 150: $578 per lifetime limitation does not apply to inpatient psychiatric
reserve day
services furnished in a general hospital.
2013.
For Medicare-covered hospital stays:
5 - Skilled Nursing
Facility (SNF)
(in a Medicarecertified skilled
nursing facility)
You get up to 190 days of
inpatient psychiatric hospital
care in a lifetime. Inpatient
psychiatric hospital services
count toward the 190-day
lifetime limitation only if certain
conditions are met. This
limitation does not apply to
inpatient psychiatric services
furnished in a general hospital.
Plan covers 60 lifetime reserve days. Cost per
lifetime reserve day:
In 2012 the amounts for each
benefit period after at least a 3day covered hospital stay were:
General
Authorization rules may apply.
Out-of-Network
For hospital stays:
In-Network
Days 1 - 20: $0 per day
Days 21 - 100: $144.50 per day
2013.
Plan covers up to 100 days each benefit period.
No prior hospital stay is required.
For Medicare-covered SNF stays:
100 days for each benefit period.
A "benefit period" starts the day
you go into a hospital or SNF. It
ends when you go for 60 days in
a row without hospital or skilled
nursing care. If you go into the
hospital after one benefit period
has ended, a new benefit period
begins. You must pay the
inpatient hospital deductible for
each benefit period. There is no
limit to the number of benefit
periods you can have.
Out-of-Network
For each SNF stay:
- Days 1 - 5: $0 copay per SNF day
- Days 6 - 100: $50 copay per SNF day
Benefit
Original Medicare
INPATIENT CARE
6 - Home Health Care $0 copay.
General
(includes medically
necessary intermittent
skilled nursing care,
home health aide
services, and
rehabilitation services,
etc.)
In-Network
10% of the cost for each Medicare-covered home
health visit.
Out-of-Network
10% of the cost for Medicare-covered home health
visits.
7 - Hospice
You pay part of the cost for
outpatient drugs and inpatient
respite care.
General
You must get care from a Medicare-certified
hospice. Your plan will pay for a consultative visit
before you select hospice.
You must get care from a
Medicare- certified hospice.
OUTPATIENT CARE
8 - Doctor Office
Visits
20% coinsurance
General
In-Network
$15 copay for each Medicare-covered primary care
doctor visit.
$40 copay for each Medicare-covered specialist
visit.
Out-of-Network
$40 copay for each Medicare-covered specialist
visit.
$20 copay for each Medicare-covered primary care
doctor visit.
Benefit
Original Medicare
Supplemental routine care not
covered
In-Network
OUTPATIENT CARE
9 - Chiropractic
Services
20% coinsurance for manual
manipulation of the spine to
correct subluxation (a
displacement or misalignment of
a joint or body part) if you get it
from a chiropractor or other
qualified providers.
$20 copay for each Medicare-covered chiropractic
visit.
Medicare-covered chiropractic visits are for manual
manipulation of the spine to correct subluxation (a
displacement or misalignment of a joint or body
part) if you get it from a chiropractor.
Out-of-Network
$20 copay for Medicare-covered chiropractic visits.
10 - Podiatry Services Supplemental routine care not
covered.
In-Network
$40 copay for each Medicare-covered podiatry visit.
20% coinsurance for medically
necessary foot care, including
care for medical conditions
affecting the lower limbs.
Medicare-covered podiatry visits are for medicallynecessary foot care.
Out-of-Network
$40 copay for Medicare-covered podiatry visits.
11 - Outpatient
Mental
Health Care
35% coinsurance for most
General
outpatient mental health services Authorization rules may apply.
Specified copayment for
outpatient partial hospitalization
program services furnished by a
hospital or community mental
health center (CMHC).
In-Network
$40 copay for each Medicare-covered individual
therapy visit.
$40 copay for each Medicare-covered group therapy
Copay cannot exceed the Part A visit.
inpatient hospital deductible.
"Partial hospitalization program" $40 copay for each Medicare-covered individual
is a structured program of active therapy visit with a psychiatrist.
outpatient psychiatric treatment
that is more intense than the care $40 copay for each Medicare-covered group therapy
received in your doctor's or
visit with a psychiatrist.
therapist's office and is an
alternative to inpatient
$40 copay for Medicare-covered partial
hospitalization.
hospitalization program services.
Benefit
Original Medicare
OUTPATIENT CARE
11 - Outpatient
Mental
Health Care
(continued)
Out-of-Network
20% of the cost for Medicare-covered partial
hospitalization program services.
$40 copay for Medicare-covered Mental Health
visits with a psychiatrist.
$40 copay for Medicare-covered Mental Health
visits.
12 - Outpatient
Substance Abuse
Care
20% coinsurance
General
In-Network
$40 copay for Medicare-covered individual
substance abuse outpatient treatment visits.
$40 copay for Medicare-covered group substance
abuse outpatient treatment visits.
Out-of-Network
25% of the cost Medicare-covered substance abuse
outpatient treatment visits.
13 - Outpatient
Services
20% coinsurance for the doctor's General
services.
Specified copayment for
outpatient hospital facility
services Copay cannot exceed
the Part A inpatient hospital
deductible.
In-Network
$100 copay for each Medicare-covered ambulatory
surgical center visit.
$100 copay for each Medicare-covered outpatient
hospital facility visit.
20% coinsurance for ambulatory
surgical center facility services. Out-of-Network
20% of the cost for Medicare-covered ambulatory
surgical center visits.
$150 copay [or 20% to 25% of the cost] for
Medicare-covered outpatient hospital facility visits.
Benefit
Original Medicare
20% coinsurance
General
OUTPATIENT CARE
14 - Ambulance
Services
(medically necessary
ambulance services)
In-Network
$100 copay for Medicare-covered ambulance
benefits.
Out-of-Network
$200 copay for Medicare-covered ambulance
benefits.
15 - Emergency Care 20% coinsurance for the doctor's
services.
(You may go to any
emergency room if you Specified copayment for
reasonably believe you outpatient hospital facility
need emergency care.) emergency services.
General
$50 copay for Medicare-covered emergency room
visits.
This amount applies toward your in-network plan
deductible.
Emergency services copay
Worldwide coverage.
cannot exceed Part A inpatient
hospital deductible for each
If you are admitted to the hospital within 48-hour(s)
service provided by the hospital. for the same condition, you pay $0 for the
emergency room visit.
You don't have to pay the
emergency room copay if you
are admitted to the hospital as an
inpatient for the same condition
within 3 days of the emergency
room visit.
Not covered outside the U.S.
except under limited
circumstances.
16 - Urgently Needed 20% coinsurance, or a set copay
Care
NOT covered outside the U.S.
(This is NOT
except under limited
emergency care, and in circumstances.
most cases,
is out of the service
area.)
General
$40 copay for Medicare-covered urgently-neededcare visits.
Benefit
Original Medicare
20% coinsurance
General
OUTPATIENT CARE
17 - Outpatient
Rehabilitation
Services
In-Network
$40 copay for Medicare-covered Occupational
Therapy visits.
(Occupational
Therapy, Physical
Therapy, Speech and
Language Therapy)
$40 copay for Medicare-covered Physical Therapy
and/or Speech and Language Pathology visits.
Out-of-Network
$40 copay for Medicare-covered Physical Therapy
and/or Speech and Language Pathology visits.
$40 copay for Medicare-covered Occupational
Therapy visits.
OUTPATIENT MEDICAL SERVICES AND SUPPLIES
18 - Durable Medical 20% coinsurance
Equipment
General
(includes wheelchairs,
oxygen, etc.)
In-Network
20% of the cost for Medicare-covered durable
medical equipment.
You may pay less if you purchase these items from
the plan's preferred manufacturers/vendors. Contact
the plan for a list of non- preferred and preferred
manufacturers/vendors.
Out-of-Network
20% of the cost for Medicare-covered durable
medical equipment.
19 - Prosthetic
Devices
(includes braces,
artificial limbs and
eyes, etc.)
20% coinsurance
General
In-Network
20% of the cost for Medicare-covered prosthetic
devices.
Out-of-Network
20% of the cost for Medicare-covered prosthetic
devices.
Benefit
Original Medicare
20 - Diabetes
Programs and
Supplies
20% coinsurance for diabetes
selfmanagement training.
General
20% coinsurance for diabetes
supplies.
In-Network
$0 copay for Medicare-covered Diabetes selfmanagement training.
20% coinsurance for diabetic
therapeutic shoes or inserts.
20% of the cost for Medicare-covered Diabetes
monitoring supplies.
Diabetic Supplies and Services are limited to
specific manufacturers, products and/or brands.
Contact the plan for a list of covered supplies.
20% of the cost for Medicare-covered Therapeutic
shoes or inserts.
Out-of-Network
20% of the cost for Medicare-covered Diabetes
monitoring supplies.
20% of the cost for Medicare-covered Therapeutic
shoes or inserts.
$0 copay for Medicare-covered Diabetes selfmanagement training.
21 - Diagnostic Tests, 20% coinsurance for diagnostic
tests and x-rays.
X- Rays, Lab
Services, and
$0 copay for Medicare-covered
Radiology Services
lab services.
Lab Services: Medicare covers
medically necessary diagnostic
lab services that are ordered by
your treating doctor when
they are provided by a Clinical
Laboratory Improvement
Amendments (CLIA) certified
laboratory that participates in
Medicare.
General
In-Network
$0 to $40 copay [or 0% to 25% of the cost] for
Medicare-covered lab services.
Medicare-covered diagnostic procedures and tests.
Medicare-covered X-rays.
$150 copay [or 20% to 25% of the cost] for
Medicare-covered diagnostic radiology services (not
including X-rays).
$40 copay [or 20% of the cost] for Medicarecovered therapeutic radiology services.
Benefit
Original Medicare
21 - Diagnostic Tests,
X- Rays, Lab
Services, and
Radiology Services
(continued)
Diagnostic lab services are done
to help your doctor diagnose or
rule out a suspected illness or
condition. Medicare does not
cover most supplemental routine
screening tests, like checking
your cholesterol.
Out-of-Network
$40 copay for Medicare-covered therapeutic
radiology services.
$20 to $40 copay for Medicare-covered outpatient
X-rays.
Medicare-covered diagnostic procedures, tests, and
lab services.
Medicare-covered diagnostic radiology services.
22 - Cardiac and
Pulmonary
Rehabilitation
Services
20% coinsurance for Cardiac
Rehabilitation services.
General
20% coinsurance for Pulmonary
Rehabilitation services.
In-Network
$0 copay for:
20% coinsurance for Intensive
Cardiac Rehabilitation services.
-Medicare-covered Cardiac Rehabilitation Services.
-Medicare-covered Intensive Cardiac Rehabilitation
This applies to program services Services.
provided in a doctors office.
Specified cost sharing for
-Medicare-covered Pulmonary Rehabilitation
program services provided by
Services.
hospital outpatient departments.
Out-of-Network
$20 copay [or 25% of the cost] for Medicarecovered Cardiac Rehabilitation Services.
$20 copay [or 25% of the cost] for Medicarecovered Intensive Cardiac Rehabilitation Services.
$20 copay [or 25% of the cost] for Medicarecovered Pulmonary Rehabilitation Services.
Benefit
Original Medicare
PREVENTIVE SERVICES, WELLNESS/EDUCATION AND OTHER SUPPLEMENTAL BENEFIT
PROGRAMS
No coinsurance, copayment or
23 -Preventive
General
deductible for the following:
$0 copay for all preventive services covered under
Services, Wellness/
Original Medicare at zero cost sharing.
Education and other
Any additional preventive services approved by
Supplemental Benefit - Abdominal Aortic Aneurysm
Screening
Medicare mid-year will be covered by the plan or by
Programs
- Bone Mass Measurement.
Original Medicare.
Covered once every 24 months
(more often if medically
In-Network
necessary) if you meet certain
$0 copay for an annual physical exam.
medical conditions.
- Cardiovascular Screening
- Cervical and Vaginal Cancer
The plan covers the following supplemental
Screening. Covered once every 2 education/wellness programs:
years. Covered once a year for
women with Medicare at high
- Health Club Membership/Fitness Classes
risk.
- Nursing Hotline
- Colorectal Cancer Screening
- Diabetes Screening
Out-of-Network
- Influenza Vaccine
$0 copay for Medicare-covered preventive services.
- Hepatitis B Vaccine for people $0 copay for an annual physical exam.
with Medicare who are at risk
- HIV Screening. $0 copay for
the HIV screening, but you
generally pay 20% of the
Medicare-approved amount for
the doctors visit. HIV screening
is covered for people with
Medicare who are pregnant and
people at increased risk for the
infection, including anyone who
asks for the test. Medicare
covers this test once every 12
months or up to three times
during a pregnancy.
- Breast Cancer Screening
(Mammogram). Medicare covers
screening mammograms once
every 12 months for all women
with Medicare age 40 and older.
Medicare covers one baseline
mammogram for women
between ages 35-39.
Benefit
Original Medicare
PROGRAMS
- Medical Nutrition Therapy
23 -Preventive
Services Nutrition therapy is for
Services, Wellness/
Education and other people who have diabetes or
Supplemental Benefit kidney disease (but aren’t on
Programs (continued) dialysis or haven’t had a kidney
transplant) when referred by a
doctor. These services can be
given by a registered dietitian
and may include a nutritional
assessment and counseling to
help you manage your diabetes
or kidney disease
- Personalized Prevention Plan
Services (Annual Wellness
Visits)
- Pneumococcal Vaccine. You
may only need the Pneumonia
vaccine once in your lifetime.
Call your doctor for more
information.
- Prostate Cancer Screening
Prostate Specific Antigen (PSA)
test only. Covered once a year
for all men with Medicare over
age 50.
- Smoking and Tobacco Use
Cessation (counseling to stop
smoking and tobacco use).
Covered if ordered by your
doctor. Includes two counseling
attempts within a 12-month
period. Each counseling attempt
includes up to four face-to-face
visits.
- Screening and behavioral
counseling interventions in
primary care to reduce alcohol
misuse
- Screening for depression in
adults
- Screening for sexually
transmitted infections (STI) and
high-intensity behavioral
counseling to prevent STIs
- Intensive behavioral counseling
for Cardiovascular Disease (biannual)
Benefit
Original Medicare
PROGRAMS
- Intensive behavioral therapy
23 -Preventive
for obesity
Services, Wellness/
Education and other - Welcome to Medicare
Supplemental Benefit Preventive Visits (initial
Programs (continued) preventive physical exam) When
you join Medicare Part B, then
you are eligible as follows.
During the first 12 months of
your new Part B coverage, you
can get either a Welcome to
Medicare Preventive Visits or an
Annual Wellness Visit. After
your first 12 months, you can get
one Annual Wellness Visit every
12 months.
24 - Kidney Disease
and Conditions
20% coinsurance for renal
dialysis.
20% coinsurance for kidney
disease education services.
In-Network
$0 copay for Medicare-covered renal dialysis.
$0 copay for Medicare-covered kidney disease
education services.
Out-of-Network
20% of the cost for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease
education services.
PRESCRIPTION DRUG BENEFITS
25 - Outpatient
Prescription Drugs
Most drugs are not covered
under Original Medicare. You
can add prescription drug
coverage to Original Medicare
by joining a Medicare
Prescription Drug Plan, or you
can get all your Medicare
coverage, including prescription
drug coverage, by joining a
Medicare Advantage Plan or a
Medicare Cost Plan that offers
prescription drug coverage.
Drugs covered under Medicare Part B
General
20% of the cost for Medicare Part B chemotherapy
drugs and other Part B drugs.
20% of the cost for Medicare Part B drugs out-ofnetwork.
Benefit
Original Medicare
25 - Outpatient
Prescription Drugs
(continued)
Drugs covered under Medicare Part D.
General
This plan uses a formulary. The plan will send you
the formulary. You can also see the formulary at
www.firstmedicare.com on the web.
Different out-of-pocket costs may apply for people
who
-have limited incomes,
-live in long term care facilities, or
-have access to Indian/Tribal/Urban (Indian Health
Service) providers.
The plan offers national in-network prescription
coverage (i.e., this would include 50 states and the
District of Columbia). This means that you will pay
the same cost-sharing amount for your prescription
drugs if you get them at an in-network pharmacy
outside of the plan's service area (for instance when
you travel).
Total yearly drug costs are the total drug costs paid
by both you and a Part D plan.
The plan may require you to first try one drug to
treat your condition before it will cover another drug
for that condition.
Some drugs have quantity limits.
Your provider must get prior authorization from
FirstMedicare Direct PPO Plus (PPO) for certain
drugs.
You must go to certain pharmacies for a very
limited number of drugs, due to special handling,
provider coordination, or patient education
requirements that cannot be met by most pharmacies
in your network. These drugs are listed on the plan's
website, formulary, printed materials, as well as on
the Medicare Prescription Drug Plan Finder on
Medicare.gov.
If the actual cost of a drug is less than the normal
cost-sharing amount for that drug, you will pay the
actual cost, not the higher cost-sharing amount.
Benefit
Original Medicare
25 - Outpatient
Prescription Drugs
(continued)
If you request a formulary exception for a drug and
FirstMedicare Direct PPO Plus (PPO) approves the
exception, you will pay Tier 4: Non-Preferred Brand
cost sharing for that drug.
In-Network
$0 deductible
Initial Coverage
You pay the following until total yearly drug costs
reach $2,970:
Retail Pharmacy
Tier 1: Preferred Generic
- $7 copay for a one-month (30-day) supply of drugs
in this tier.
- $14 copay for a two-month (60-day) supply of
drugs in this tier.
- $21 copay for a three-month (90-day) supply of
drugs in this tier.
Tier 2: Non-Preferred Generic
- $25 copay for a one-month (30-day) supply of
drugs in this tier.
drugs in this tier.
drugs in this tier.
Tier 3: Preferred Brand
drugs in this tier.
drugs in this tier.
drugs in this tier.
Tier 4: Non-Preferred Brand
drugs in this tier.
drugs in this tier.
drugs in this tier
Benefit
Original Medicare
25 - Outpatient
Prescription Drugs
(continued)
Tier 5: Specialty Tier
- 33% coinsurance for a one-month (30-day) supply
of drugs in this tier.
- 33% coinsurance for a two-month (60-day) supply
- 33% coinsurance for a three-month (90-day)
supply of drugs in this tier.
Not all drugs on this tier are available at this
extended day supply. Please contact the plan for
more information.
Long Term Care Pharmacy
in this tier.
drugs in this tier.
drugs in this tier.
drugs in this tier.
Please note that brand drugs must be dispensed
incrementally in long- term care facilities. Generic
drugs may be dispensed incrementally. Contact your
plan about cost-sharing billing/collection when less
than a one-month supply is dispensed.
Benefit
Original Medicare
25 - Outpatient
Prescription Drugs
(continued)
Mail Order
in this tier
- $0 copay for a two-month (60-day) supply of drugs
in this tier.
drugs in this tier.
drugs in this tier.
drugs in this tier.
- $62.50 copay for a three-month (90-day) supply of
drugs in this tier.
drugs in this tier.
drugs in this tier.
drugs in this tier.
drugs in this tier.
drugs in this tier.
drugs in this tier.
- 33% coinsurance for a two-month (60-day) supply
- 33% coinsurance for a three-month (90-day)
supply of drugs in this tier
Not all drugs on this tier are available at this
extended day supply. Please contact the plan for
more information.
Benefit
Original Medicare
25 - Outpatient
Prescription Drugs
(continued)
Coverage Gap
After your total yearly drug costs reach $2,970, you
receive limited coverage by the plan on certain
drugs. You will also receive a discount on brand
name drugs and generally pay no more than 47.5%
for the plan's costs for brand drugs and 79% of the
plan's costs for generic drugs until your yearly outof-pocket drug costs reach $4,750.
Additional Coverage Gap
The plan covers few formulary generics (less than
10% of formulary generic drugs) through the
coverage gap.
The plan offers additional coverage in the gap for
the following tiers. You pay the following:
Retail Pharmacy
- $7 copay for a one-month (30-day) supply of all
drugs covered in this tier.
- $14 copay for a two-month (60-day) supply of all
- $21 copay for a three-month (90-day) supply of all
Long Term Care Pharmacy
Please note that brand drugs must be dispensed
incrementally in long- term care facilities. Generic
drugs may be dispensed incrementally. Contact your
plan about cost-sharing billing/collection when less
than a one-month supply is dispensed.
Mail Order
- $14 copay for a two-month (60-day) supply of all
- $21 copay for a three-month (90-day) supply of all
Benefit
Original Medicare
25 - Outpatient
Prescription Drugs
(continued)
Catastrophic Coverage
After your yearly out-of-pocket drug costs reach
$4,750, you pay the greater of:
-5% coinsurance, or
- $2.65 copay for generic (including brand drugs
treated as generic) and a $6.60 copay for all other
drugs.
Out-of-Network
Plan drugs may be covered in special circumstances,
for instance, illness while traveling outside of the
plan's service area where there is no network
pharmacy. You may have to pay more than your
normal cost-sharing amount if you get your drugs at
an out-of-network pharmacy. In addition, you will
likely have to pay the pharmacy's full charge for the
drug and submit documentation to receive
reimbursement from FirstMedicare Direct PPO Plus
(PPO).
Out-of-Network Initial Coverage
You will be reimbursed up to the plan's cost of the
drug minus the following for drugs purchased outof-network until total yearly drug costs reach
$2,970:
in this tier.
drugs in this tier.
drugs in this tier.
drugs in this tier.
You will not be reimbursed for the difference
between the Out-of- Network Pharmacy charge and
the plan's In-Network allowable amount.
Benefit
Original Medicare
25 - Outpatient
Prescription Drugs
(continued)
Out-of-Network Coverage Gap
You will be reimbursed up to 21% of the plan
allowable cost for generic drugs purchased out-ofnetwork until total yearly out-of- pocket drug costs
reach $4,750. Please note that the plan allowable
cost may be less than the out-of-network pharmacy
price paid for your drug(s).
You will be reimbursed up to 52.5% of the plan
allowable cost for brand name drugs purchased outof-network until your total yearly out-of-pocket
drug costs reach $4,750. Please note that the plan
allowable cost may be less than the out-of-network
pharmacy price paid for your drug(s).
Additional Out-of-Network Coverage Gap
The plan covers few formulary generics (less than
10% of formulary generic drugs) through the
coverage gap.
You will be reimbursed for these drugs purchased
out-of-network up to the plan's cost of the drug
minus the following:
Out-of-Network Catastrophic Coverage
After your yearly out-of-pocket drug costs reach
$4,750, you will be reimbursed for drugs purchased
out-of-network up to the plan's cost of the drug
minus your cost share, which is the greater of:
- 5% coinsurance, or
- $2.65 copay for generic (including brand drugs
treated as generic) and a $6.60 copay for all other
drugs.
Benefit
Original Medicare
26 - Dental Services
Preventive dental services (such
as cleaning) not covered.
In-Network
In general, preventive dental benefits (such as
cleaning) not covered.
$40 copay for Medicare-covered dental benefits.
Out-of-Network
$40 copay for Medicare-covered comprehensive
dental benefits.
27 - Hearing Services Supplemental routine hearing
exams and hearing aids not
covered.
20% coinsurance for diagnostic
hearing exams.
In-Network
In general, supplemental routine hearing exams and
hearing aids not covered.
$40 copay for Medicare-covered diagnostic hearing
exams.
Out-of-Network
$40 copay for Medicare-covered diagnostic hearing
exams.
28 - Vision Services
20% coinsurance for diagnosis
and treatment of diseases and
conditions of the eye.
In-Network
- 20% of the cost for one pair of Medicare-covered
eyeglasses or contact lenses after cataract surgery.
Supplemental routine eye exams - $0 to $40 copay for Medicare-covered exams to
and glasses not covered.
diagnose and treat diseases and conditions of the
eye.
Medicare pays for one pair of
eyeglasses or contact lenses after - $40 copay for up to 1 supplemental routine eye
cataract surgery.
exam(s) every year.
Annual glaucoma screenings
covered for people at risk.
Out-of-Network
20% of the cost for Medicare-covered eye wear.
$40 copay for supplemental eye exams.
$0 to $40 copay for Medicare-covered eye exams.
$100 plan coverage limit for supplemental routine
eye exams every year. This limit applies to both innetwork and out-of-network benefits.
Benefit
Original Medicare
Over-the-Counter
Items
Not covered.
General
The plan does not cover Over-the-Counter items.
Transportation
(Routine)
Not covered.
In-Network
This plan does not cover supplemental routine
transportation.
Acupuncture
Not covered.
In-Network
This plan does not cover Acupuncture.
2013 Medicare Advantage Prescription Drug Plan (MAPD) Individual Enrollment Form
Please contact FirstMedicare Direct if you need information in another language or format (Braille).
To Enroll in FirstMedicare Direct Secure Please Provide the Following Information:
Please check which plan you want to enroll in:
 HMO Plus (HMO) ($0/month)
 PPO Plus (PPO) ($49.90 /month)
Effective Date: The date you want coverage to begin. In general, requests to enroll will be effective on the first day of
the month after this form is received. _____ Month _____ Year
LAST Name:
FIRST Name:
Birth Date:
( __ __ / __ __ / __ __ __ __ )
(M M/DD/ YYY Y)
Sex:
 Male  Female
Middle Initial:
 Mr.  Mrs.  Ms.
Home Phone Number: Alternate Phone Number:
(
)
(
)
Permanent Residence Street Address ( P.O. Box is not allowed ):
City:
NC
County:
Mailing Address ( Only if different from your Permanent Residence Address )
Street Address or Post Office Box:
ZIP Code:
City:
State:
ZIP Code:
 Emergency Contact or
Phone Number: (
)
Your E-mail Address:
 Power of Attorney (POA)
Relationship to You:________________
Name: ____________________________
Please Provide Your Medicare Insurance Information
Please take out your Medicare card to complete this
section.
 Please fill in the blanks to the right so they match
your red, white and blue Medicare card
SAMPLE ONLY
- OR –
Name: _____________________________________
 Attach a copy of your Medicare card or your letter
Medicare Claim Number:_______________ Sex: ___
from Social Security or the Railroad Retirement
Board. You must have Medicare Part A and Part B Is Entitled To Effective Date
HOSPITAL (PART A) __________________________
to join a Medicare Advantage Plan.
MEDICAL (PART B) __________________________
Paying Your Plan Premium
You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe)
by any of the following methods: You can receive a paper invoice in the mail each month and mail FirstCarolinaCare
a check for the premiums due. You can pay your bill automatically each month from a checking or savings account
using Electronic Funds Transfer. You can pay your bill automatically each month using a Master or VISA Card. You
can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board
(RRB) benefit check each month. No matter which method you select, you must continue to pay your Part B premiums
to Social Security in addition to the FirstCarolinaCare plan premiums.
If you previously qualified for Medicare prescription drug coverage, but decided not to carry prescription coverage at
least as good as Medicare’s, then Medicare may determine that you owe a monthly Late Enrollment Penalty.
H8064_13_29 CMS Approved 09282012
Last Updated 09/27/2012
If Medicare informs FirstCarolinaCare that you owe this late enrollment penalty, it will be included in your
monthly premium, even if you sign up for a $0 premium plan. If it is determined that you owe a late enrollment
penalty, we need to know how you would prefer to pay it.
If you are assessed a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you will be notified
by the Social Security Administration. You will be responsible for paying this extra amount in addition to your
plan premium. You will either have the amount withheld from your Social Security benefit check or be billed
directly by Medicare or the RRB. DO NOT pay FirstCarolinaCare the Part D-IRMAA.
People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you qualify,
Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual
deductibles and co-insurance. Additionally, those who qualify won’t have a coverage gap or a late enrollment
penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra
help, contact your local Social Security office or call Social Security at 1-800-772-1213. TTY users should call 1800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.
If you have recently been enrolled in Medicaid or you have received a letter stating that you have qualified for
Qualified Medicare Beneficiary (QMB) or Specified Low-Income Medicare Beneficiary (SLMB) status, you
automatically qualify for Prescription Drug Assistance. If you need a prescription filled before FirstCarolinaCare
receives confirmation from the Centers for Medicare and Medicaid Services (CMS) of your eligibility status,
please contact our Customer Service Department for assistance. The qualifications for Prescription Drug
Assistance are based on income and assets. If you do qualify, Medicare would pay for a portion of your total
monthly premium. FirstCarolinaCare would bill you for the balance of your premium. If you qualify for extra
help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If
Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover.
Please select a premium payment option:
(If you don’t select a payment option, we will mail you a bill each month)
 Get a monthly bill in the mail
.
 Electronic funds transfer (EFT) from your bank account each month. Please enclose a
VOIDED check if possible and provide the following:
Account Holder Name: _________________________________
Bank Routing Number: _________________________________
Bank Account Number: _________________________________
Account Type:
 Checking
 Savings
 Electronic charge to your VISA or MasterCard each month.
Please provide the following:
Credit Card Type:
 VISA
 MasterCard
Name of Account Holder as it appears on card:________________________
Account Number:_______________________________________________
CVV Number (3-digit code on the back of your card):________Expiration Date (MM/YYYY):______________
H8064_13_29 CMS Approved 09282012
 Automatic deduction from your monthly Social Security or Railroad Retirement Board
(RRB) benefits check.
PLEASE NOTE: The Social Security deduction may take two or more months to begin after Social Security or RRB
approves the deduction. Usually, the effective date of the deduction will NOT be the same as your enrollment
effective date with FirstCarolinaCare. FirstCarolinaCare will send you a monthly bill in the mail until we receive
notification from Medicare as to which month they begin taking the money out of your Social Security check. You
are responsible for paying by check until such time as we have established the effective date of your withhold.
*You should know that Social Security LIMITS the automatic deduction amount allowed from your benefit check to
$200. For example, should you select the FirstCarolinaCare Secure Gold or Platinum plan and there is a two month
delay in processing, the entire transaction will be rejected by Social Security because the deduction amount would
exceed $200. You will then default back to being billed by mail for all unpaid premiums.
Please read and answer these important questions:
1. Do you have End Stage Renal Disease (ESRD)?  Yes  No
If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, please attach
a note or records from your doctor showing you have had a successful kidney transplant or you don’t need
dialysis, otherwise we may need to contact you to obtain additional information.
2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal
employee health benefits coverage, VA benefits or State pharmaceutical assistance programs.
Will you have other prescription drug coverage in addition to FirstCarolinaCare?  Yes  No
If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage:
Name of other coverage:
____________________
ID # for this coverage:
____________________
Group # for this coverage:
_________________________
3. Are you a resident in a long-term care facility, such as a nursing home?  Yes  No
If “yes” please provide the following information:
Name of Institution: ________________________ Address & Phone Number:_______________________________
4. Are you enrolled in your State Medicaid program?  Yes  No
If “yes” please provide your Medicaid number: ____________________
5. Do you or your spouse work? Yes No
Please choose your Primary Care Physician (PCP). You may search the FirstMedicare Direct Provider/Pharmacy
Directory or search online at www.firstmedicare.com and click on “Find Your Doctor or Hospital”:
Name: ________________________________________ PCP Code: ____________________
If you or someone you know would benefit from having our information in a language other than English OR in
another format such as large print, audiotape or Braille, please contact FirstCarolinaCare Sales at 877-279-1732
From October 1, 2012, through February 14, 2013, a representative will be available to speak with you from 8 a.m.
to 8 p.m. seven days a week. Beginning February 15, 2013, through September 30, 2013, a representative will be
available to speak with you from 8 a.m. to 8 p.m. Monday through Friday.
Please Read This Important Information
If you have health coverage from an employer or union that you are going to be keeping, joining FirstCarolinaCare
may change how that coverage works. Please contact the Benefits Administration office at your former employer if
you have questions about how these two insurances will work together.
H8064_13_29 CMS Approved 09282012
Please Read and Sign Below:
By completing this enrollment application, I agree to the following: FirstCarolinaCare is a Medicare Advantage plan
and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one
Medicare Advantage plan at a time and I understand that my enrollment in this plan will automatically end my
enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any
prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year.
Once I enroll, I may leave this plan or make changes at certain times of the year when an enrollment period is
available (example: October 15 – December 7 of every year) or under certain special circumstances.
FirstCarolinaCare serves a specific service area. If I move out of FirstCarolinaCare’s service area, I will need to enroll
in a new plan for my new area. I understand that FirstCarolinaCare provides medical and prescription drug coverage
when I travel and I will have emergency coverage if I travel outside of the US. I understand that the Evidence of
Coverage I receive will tell me what benefits I have under FirstCarolinaCare and which rules I must follow to get
those benefits. I understand that services requiring an authorization will be denied if no authorization information is
received from the doctor. I understand that I have the right to appeal decisions about payments and services if I
disagree with FirstCarolinaCare. I understand that while I am a member of any FirstCarolinaCare plan, I must use
FirstCarolinaCare providers in order to get the higher level of coverage, but the copay for urgent care or emergency
care or dialysis services will be the same in-network and out-of-network. If medically necessary, FirstCarolinaCare
provides refunds for all covered benefits, even if I get services out-of-network.
I understand that if I am getting assistance from a sales agent, broker or other individual employed by or contracted
with FirstCarolinaCare, he/she may be paid based on my enrollment in FirstCarolinaCare.
Release of Information: By joining this Medicare health plan, I acknowledge that FirstCarolinaCare will release my
information to Medicare and other plans or providers as is necessary for treatment, payment and health care
operations. I also acknowledge that FirstCarolinaCare will release my information including my prescription drug
event data to Medicare, who may release it for research and other purposes which follow all applicable Federal
statutes and regulations. The information on this enrollment form is correct to the best of my knowledge.
I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.
I understand that my signature on this application means that I have read and understand the contents. If this
application is signed by an authorized individual such as a Power of Attorney or Legal Guardian, I understand that
FirstCarolinaCare or Medicare may request a copy of those documents for their files.
Your Signature:
Today’s Date:
If you are the authorized representative and/or have Power of Attorney (POA), you must sign above and provide the
following information along with your POA form:
Name: ____________________________________________________________ Address:
____________________________________________________________
Phone Number: ________________________ Relationship to Enrollee: ________________________
Sales Agent Name: ________________________________ Agent Code: ________________________
Please KEEP a copy for your records.
H8064_13_29 CMS Approved 09282012
Typically, you may enroll in a Medicare Advantage Plan during the annual enrollment period which is
from October 15 through December 7. There are exceptions that allow you to enroll in a Medicare
Advantage Plan outside of this period.
*Please read the following statements carefully and check the box if the statement applies to you. By
checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for
an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.





















I am enrolling during the annual enrollment period between October 15 and December 7.
I am new to Medicare.
I have had Medicare prior to now, but am just turning age 65.
I recently moved or within the next month I will move outside of the service area for my current plan
and into the service area for FirstCarolinaCare. I moved or will move on (insert date): ____________
I was terminated from my prior Medicare plan for living outside of its service area for more than six
months. I was terminated on (insert date): ________________
I was recently released from a correctional facility on (insert date):_______________
I have both Medicare and Medicaid or my state helps pay for my Medicare premiums.
I get extra help paying for Medicare prescription drug coverage.
I no longer qualify for extra help paying for my Medicare prescription drugs. I stopped receiving extra
help on (insert date):_________________
I am moving into a Long-Term Care Facility (for example, a nursing home or rehabilitation hospital).
I will move into the facility on (insert date): __________________
I currently live in a Long-Term Care Facility.
I recently moved out of a Long-Term Care Facility on (insert date): _______________
I recently left a PACE program on (insert date): _____________
I recently involuntarily lost my creditable prescription drug coverage (coverage as good as
Medicare’s). I lost my drug coverage on (insert date): ________________
I am leaving employer or union coverage on (insert date): __________________
I belong to a pharmacy assistance program provided by my state.
I was unable to enroll in a Medicare Drug Plan when I first became eligible for Medicare, because no
plan was available where I lived at that time (for example, I lived outside of the country or was
incarcerated.) I first moved into an area where I could sign up for a Medicare Drug Plan on (insert
date):
My prior Medicare (Advantage or Prescription Drug) plan (not FirstCarolinaCare) is ending its
contract with Medicare or Medicare is ending its contract with my old plan, so I need a new plan.
I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to
be in that plan. I was disenrolled from the SNP on (insert date):__________________
I recently returned to the United States after living permanently outside of the U.S. I returned to the
U.S. on (insert date): ____________________
I used the Medicare Advantage Disenrollment Period (MADP) to disenroll from my Medicare plan
between January 1 and February 14.
*If none of these statements apply to you or you have any questions about this form, please contact
FirstCarolinaCare Sales for assistance at 877-279-1732 Persons with hearing impairments please call TTY at
711. From October 1, 2012 through February 14, 2013, a representative will be available to speak with you
from 8 a.m. to 8 p.m. seven days a week. Beginning February 15, 2013, through September 30, 2013, a
representative will be available to speak with you from 8 a.m. to 8 p.m. Monday through Friday.
FirstMedicare Direct HMO Plus and PPO Plus
2013 Abridged Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE
COVER IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this document
to make sure that it still contains the drugs you take.
This document includes FirstMedicare Direct’s partial formulary as of January 1, 2013. For a
complete, updated formulary, please visit our Web site at www.firstmedicare.com or call (888) 3507794, 24 hours seven days a week. TTY/TDD users should call 711.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary,
pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2014.
FirstCarolinaCare Insurance Company is a health plan with a Medicare contract.
This document may be available in alternate formats or other languages. For more information, please call
Member Services at (888) 350-7794, 24 hours seven days a week. TTY/TDD users should call 711.
H8064_13_18, CMS Accepted 09292012
Last Updated: 09012012
Version Number: 5
1 |2013 Abridged Formulary
What is the FirstMedicare Direct Formulary?
A formulary is a list of covered drugs selected by FirstMedicare Direct in consultation with a team of health
care providers, which 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. For more information on how to fill your prescriptions, please review your Evidence
of Coverage.
This document is a partial formulary and includes only some of the drugs covered by FirstMedicare Direct.
For a complete listing of all prescription drugs covered by FirstMedicare Direct, please visit our Web site at
www.firstmedicare.com or call (888) 350-7794, 24 hours seven days a week. TTY/TDD users should call
711.
Can the Formulary change?
Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year, we
will not discontinue or reduce coverage of the drug during the 2013 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.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the
change at least 60 days before the change becomes effective, or at the time the member requests a refill of the
drug, at which time the member will receive a 60- day supply of the drug. If the Food and Drug
Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug
from the market, we will immediately remove the drug from our formulary and provide notice to members
who take the drug. The enclosed formulary is current as of January 1, 2013. To get updated information
about the drugs covered by FirstMedicare Direct, please visit our Web site at www.firstmedicare.com or call
Member Services at (888) 350-7794, 24 hours seven days a week. TTY/TDD users should call 711. If nonmaintenance formulary changes occur during the plan year, members will be provided notice and the
printable formulary will updated and posted on our website at www.firstmedicare.com.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 12. The drugs in this formulary are grouped into categories depending on the
type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are
listed under the category, “Cardiac Drugs”. If you know what your drug is used for, look for the category
name in the list that begins below. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on
page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand
name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your
drug, you will see the page number where you can find coverage information. Turn to the page listed in the
Index and find the name of your drug in the first column of the list.
What are generic drugs?
FirstMedicare Direct covers both brand name drugs and generic drugs. A generic drug is approved by the
FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than
brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:
• Prior Authorization: FirstMedicare Direct requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from FirstMedicare
Direct before you fill your prescriptions. If you don’t get approval, FirstMedicare Direct may not
cover the drug.
• Quantity Limits: For certain drugs, FirstMedicare Direct limits the amount of the drug that
FirstMedicare Direct will cover. For example, FirstMedicare Direct provides 30 tablets per
prescription for rosiglitazone. This may be in addition to a standard one month or three month
supply.
• Step Therapy: In some cases, FirstMedicare Direct requires you to first try certain drugs to treat
your medical condition before we will cover another drug for that condition. For example, if Drug
A and Drug B both treat your medical condition, FirstMedicare Direct may not cover Drug B
unless you try Drug A first. If Drug A does not work for you, FirstMedicare Direct will then
cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 12. You can also get more information about the restrictions applied to specific covered drugs
by visiting our Web site at www.firstmedicare.com.
You can ask FirstMedicare Direct to make an exception to these restrictions or limits. See the section, “How
do I request an exception to the FirstMedicare Direct’s formulary?” on page 4 for information about how to
request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this list of covered drugs, you should first contact Member Services and ask if
your drug is covered. This document includes only a partial list of covered drugs, so FirstMedicare Direct
may cover your drug. You can contact Member Services at (888) 350-7794, 24 hours seven days a week.
TTY/TDD users should call 711.
If you learn that FirstMedicare Direct does not cover your drug, you have two options:
• You can ask Member Services for a list of similar drugs that are covered by FirstMedicare Direct.
When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug
that is covered by FirstMedicare Direct.
• You can ask FirstMedicare Direct to make an exception and cover your drug. See below for
information about how to request an exception.
How do I request an exception to FirstMedicare Direct’s Formulary?
You can ask FirstMedicare Direct to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.
• You can ask us to cover your drug even if it is not on our formulary.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain a
drug, FirstMedicare Direct limits the amount of the drug that we will cover. If your drug has a
quantity limit, you can ask us to waive the limit and cover more.
• You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our
non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the
preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we
grant your request to cover a drug that is not on our formulary, you may not ask us to provide a
higher level of coverage for the drug. Also, you may not ask us to provide a higher level of
coverage for drugs that are in the Specialty tier.
Generally, FirstMedicare Direct will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as
effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you are requesting a formulary, tiering or utilization restriction exception
you should submit a statement from your physician supporting your request. Generally, we must make
our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement.
You can request an expedited (fast) exception if you or your doctor believe that your health could be
seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must
give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s
supporting statement.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need
a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide
if you should switch to an appropriate drug that we cover or request a formulary exception so that we will
cover the drug you take. While you talk to your doctor to determine the right course of action for you, we
may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a
network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a
member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with a 98-day transition supply, consistent with the dispensing increment, (unless you have a
prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days
you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your
drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary
exception.
Transition medications will be provided to members who change treatment settings due to changes in level of
care (e.g. individuals who enter long term care facilities from hospitals or enter an ambulatory setting from a
hospital).
For more information
For more detailed information about your FirstMedicare Direct prescription drug coverage, please review
your Evidence of Coverage and other plan materials.
If you have questions about FirstMedicare Direct, please call Member Services at (888) 350-7794, 24 hours
seven days a week. TTY/TDD users should call 711. Or visit www.firstmedicare.com.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours seven days a week. TTY/TDD users should call 1-877-486-2048.
Or, visit www.medicare.gov.
FirstMedicare Direct’s Formulary
The abridged formulary below provides coverage information about some of the drugs covered by
FirstMedicare Direct. If you have trouble finding your drug in the list, turn to the Index that begins on page I1. Remember: This is only a partial list of drugs covered by FirstMedicare Direct. If your prescription is not
in this partial formulary, please visit our Web site at www.firstmedicare.com or call Member Services at
(888) 350-7794, 24 hours seven days a week. TTY/TDD users should call 711 for additional help.
The first column of the chart lists the drug name. Brand name drugs are capitalized e.g., JANUVIA) and
generic drugs are listed in lower-case italics (e.g., simvastatin).
The information in the Requirements/Limits column tells you if FirstMedicare Direct has any special
requirements for coverage of your drug.
The following copayments are associated with the corresponding tiers if you receive the drugs at an innetwork pharmacy during the initial coverage phase. Please review your EOC for additional benefit
information.
FirstMedicare Direct HMO Plus
FirstMedicare Direct PPO Plus
Tier
Copay Amounts
T1 = Tier 1 Preferred Generic Drugs
$7
Retail, 30-Day Supply
$14
$21
$0
Mail Order, 90-Day Supply
Tier
Copay Amounts
T1 = Tier 1 Preferred Generic Drugs
$7
$14
$21
$0
T2 = Tier 2 Non-Preferred Generic Drugs
$25
$50
$75
$62.50
T2 = Tier 2 Non-Preferred Generic Drugs
$25
$50
$75
$62.50
T3 = Tier 3 Preferred Brand Name Drugs
$40
$80
$120
$100
T3 = Tier 3 Preferred Brand Name Drugs
$40
$80
$120
$100
T4 =Tier 4 Non-Preferred Brand Name Drugs
$80
$160
$240
$200
T4 =Tier 4 Non-Preferred Brand Name Drugs
$80
$160
$240
$200
T5 = Tier 5 Specialty Drugs
33%
co-pay Retail, 30-Day Supply
33%
co-pay Mail Order, 30-Day Supply
T5 = Tier 5 Specialty Drugs
33%
co-pay Retail, 30-Day Supply
33%
co-pay Mail Order, 30-Day Supply
The following abbreviations may be found within the body of this document
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION
GENERAL
DESCRIPTION
EXPLANATION
The reference brand name in parentheses is provided
for information only, to assist in identifying the generic
generic(Brand)
medication and does NOT indicate formulary status or
coverage
UTILIZATION MANAGEMENT RESTRICTIONS
You (or your physician) are required to get prior
Prior Authorization
authorization from FirstMedicare Direct before you fill
PA
Restriction
your prescription for this drug. Without prior approval,
FirstMedicare Direct may not cover this drug.
FirstMedicare Direct limits the amount of this drug that
QL
Quantity Limit Restriction is covered per prescription, or within a specific time
frame.
Before FirstMedicare Direct will provide coverage for
this drug, you must first try another drug(s) to treat
ST
Step Therapy Restriction
your medical condition. This drug may only be covered
if the other drug(s) does not work for you.
OTHER SPECIAL REQUIREMENTS FOR COVERAGE
We provide coverage of this prescription drug in the
GC
Gap Coverage
coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
This prescription may be available only at certain
pharmacies. For more information consult your
LA
Limited Access Drug
Pharmacy Directory or call Member Services at (888)
350-7794, 24 hours seven days a week. TTY/TDD
users should call 711.
STRENGTH AND DOSAGE FORM ABBREVIATIONS
ABBREVIATION
adh. patch
aer br act
aer pow
aer pow ba
aer refill
aer w/adap
ampul
blkbaginj
cap dr mp
cap ds pk
cap er 12h
cap er 24h
cap er deg
cap er pel
cap mphase
cap.sa 24h
cap.sr 12h
cap.sr 24h
cap24h pct
cap24h pel
cap sprink
cap sr pel
cap w/dev
capsule dr
capsule er
capsule sa
cmb cappad
cmb ont fm
cmb ont lt
cmb tabpad
combo. pkg
cpmp 12hr
cpmp 24hr
cpmp 30-70
cpmp 50-50
cream(g), cream(gm)
cream(ml)
cream/appl
cream, er (g)
cream pack
dehp fr bg
dis needle
disk w/dev
disp syrin
DESCRIPTION
adhesive patch
aerosol, breath activated
aerosol, powder
aerosol powder, breath activated
aerosol refill
aerosol with adapter
ampule
bulk bag injection
capsule, delayed release multiphasic
capsule, dose pack
capsule, 12 hour extended release
capsule, 24 hour extended release
capsule, extended release degradable
capsule, extended release pellets
capsule, multiphasic
capsule, 24 hour sustained action
capsule, 12 hour sustained release
capsule, 24 hour sustained release
capsule, 24 hour controlled-onset pellets
capsule, 24 hour sustained release pellets
capsule, sprinkle
capsule sustained release pellets
capsule with device
capsule, delayed release
capsule, extended release
capsule, sustained action
combination: capsule, pad
combination: ointment, foam
combination: ointment, lotion
combination: tablet, pad
combination package
capsule, 12 hour multiphasic
capsule, 24 hour multiphasic
capsule, multiphasic, 30%-70%
capsule, multiphasic, 50%-50%
cream (grams)
cream (milliliters)
cream with applicator
cream, extended release (grams)
cream, package
di(2-ethylhexyl)phthalate free bag
disposable needle
disk with inhalation device
disposable syringe
ABBREVIATION
drops susp
drps hpvis
emul adhes
emul packt
emulsn(g)
foam/appl.
froz.piggy
g
gel/pf app
gel (gm)
gel (ml)
gel md pmp
gel w/appl
gel w/pump
gran pack
hfa aer ad
infus. btl
insuln pen
ip soln
irrig soln
iv soln.
jel
jelly/app
jel/pf app
kit cl&crm
kt crm le
kt lotn ce
kt oint le
lotion, er
lozenge hd
m.ht patch
ma buc tab
mcg
med. pad
med. swab
med. tape
mg
ml
muc er 12h
ndl fr inj
nl fm susp
oint. (g), oint.(gm)
oral conc
oral susp
paste (g)
patch td24
DESCRIPTION
drops, suspension
drops, hyperviscous
emulsion adhesive
emulsion packet
emulsion (grams)
foam with applicator
frozen piggyback
gram
gel with prefilled applicator
gel (grams)
gel (milliliters)
gel in metered dose pump
gel with applicator
gel with pump
granule pack
hfa aerosol adapter
infusion bottle
insulin pen
intraperitoneal solution
irrigating solution
intravenous solution
jelly
jelly with applicator
jelly with pre-filled applicator
kit: cleasner and cream
kit: cream, lotion emollient
kit: lotion, cream emollient
kit: ointment, lotion emollient
lotion, extended release
lozenge handle
medicated heated patch
mucoadhesive buccal tablet
microgram
medicated pad
medicated swab
medicated tape
milligram
milliliter
mucoadhesive system, 12 hour extended release
needle for injection
nail film suspension
ointment (grams)
oral concentrate
oral suspension
paste (grams)
patch, 24 hour transdermal
ABBREVIATION
patch td72
patch tdsw
patch tdwk
pca syring
pca vial
pellet(ea)
pen ij kit
pen injctr
pggybk btl
plast. bag
powd pack
sol md pmp
sol w/appl
sol/pf app
sol-gel
soln recon
soln(gram)
spray susp
spray/pump
stick(ea)
supp.rect
supp.vag
suppos.
sus er 24h
sus er rec
sus mc rec
suspdr pkt
susp recon
syringekit
tab chew
tab er 12h
tab er 24h
tab er prt
tab er seq
tab disper
tab ds pk
tab er 24
tab mphase
tab part
tab rap dr
tab rapdis
tab subl
tab.sr 12h
tab.sr 24h
tabergr24hr
tablet dr
DESCRIPTION
patch, 72 hour transdermal
patch, biweekly transdermal
patch, weekly transdermal
patient-controlled analgesic syringe
patient-controlled analgesic vial
pellet (each)
pen injector kit
pen injector
piggyback bottle
plastic bag
powder pack
solution with multi-dose pump
solution with applicator
solution with pre-filled applicator
solution, gel-forming
solution, reconstituted
solution (grams)
spray, suspension
spray with pump
stick (each)
suppository, rectal
suppository, vaginal
suppository
suspension, 24 hour extended release
suspension, extended release reconstituted
suspension, microcapsule reconstituted
suspension, delayed release packet
suspension, reconstituted
syringe kit
tablet, chewable
tablet, 12 hour extended release
tablet, extended release particles
tablet, extended release sequels
tablet, dispersable
tablet, dose pack
tablet, multiphasic
tablet, particles
tablet, rapid disintegrating delayed release
tablet, rapid disintegrating
tablet, sublingual
tablet, 12 hour sustained release
tablet, 24 hour sustained release
tablet, 24 hour gradual extended release
tablet, delayed release
ABBREVIATION
tablet, er
tablet eff
tablet sa
tablet sol
tb er dspk
tb mp dspk
tb rd dspk
tbdspk 3mo
tbmp 12hr
tbmp 24hr
u
vag ring
DESCRIPTION
tablet, extended release
tablet, effervescent
tablet, sustained action
tablet, soluble
tablet, extended release dosepack
tablet, multiphasic dosepack
tablet, rapid disintegrating dosepack
tablet, 3-month dosepack
tablet, 12 hour multiphasic
tablet, 24 hour multiphasic
unit
vaginal ring
Drug Name
Drug
Tier
Requirements/Limits
Adrenals
Adrenals
ADVAIR DISKUS
3
ADVAIR HFA
3
FLOVENT DISKUS
3
FLOVENT DISKUS
3
FLOVENT HFA
3
FLOVENT HFA
3
FLOVENT HFA
3
methylprednisolone
(Medrol)
2
QL: 62 in
31 days
QL: 12 in
28 days
QL: 120
in 30
days
QL: 60 in
30 days
QL: 12 in
28 days
QL: 21.2
in 28
days
QL: 24 in
28 days
PA
4
PA
PREDNISONE
INTENSOL
prednisone
(Prednisone)
1
GC, PA
prednisone
(Prednisone)
2
PA
QVAR
3
SYMBICORT
4
QL: 17.4
in 25
days
ST, QL:
11 in 25
days
disk w/dev: 250mcg
disk w/dev: 50mcg,
100mcg
aer w/adap: 110mcg
aer w/adap: 44mcg
aer w/adap: 220mcg
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
tablet, (PA for Part
B vs Part D Only)
solution, (PA for
Part B vs Part D
Only)
Alpha-Adrenergic Blocking Agents
(Cardura)
doxazosin mesylate
(Hytrin)
terazosin hcl
1
1
GC
GC
Ammonia Detoxicants
Ammonia Detoxicants
BUPHENYL
12
FirstCarolinaCare Insurance Company 2013 Part D Formulary
Formulary ID: 13382.000, Version: 5
3
Effective: January 01, 2013
Drug Name
lactulose
(Lactulose)
Drug
Tier
Requirements/Limits
2
solution
Analgesics and Antipyretics
Nonsteroidal Anti-inflammatory Agents
CELEBREX
diclofenac sodium
ibuprofen
ibuprofen
meloxicam
meloxicam
nabumetone
naproxen
naproxen
SOLARAZE
VOLTAREN
Opiate Agonists
acetaminophen with
codeine
(Voltaren)
(Ibuprofen)
(Motrin)
(Mobic)
(Mobic)
(Relafen)
(Naprosyn)
(Naprosyn)
3
2
2
1
1
2
2
1
2
4
3
(Tylenol-codeine No.3)
2
acetaminophen with
codeine
(Tylenol-codeine No.3)
2
hydrocodone bit/
acetaminophen
(Hycet)
2
hydrocodone bit/
acetaminophen
(Vicodin)
2
hydrocodone bit/
acetaminophen
(Vicodin)
2
hydrocodone bit/
acetaminophen
(Vicodin)
2
hydrocodone bit/
acetaminophen
(Vicodin)
2
13
ST, QL:
62 in 31
days
oral susp
tablet
tablet
oral susp
GC
GC
GC
tablet
oral susp, tablet dr
ST
gel (gram),
(Topical Gel)
QL: 180
in 30
days
QL: 360
in 30
days
QL: 2700
in 30
days
QL: 150
in 30
days
QL: 180
in 30
days
QL: 240
in 30
days
tablet: 300mg-60mg
QL: 360
in 30
days
tablet: 300mg15mg, 300mg-30mg
solution: 7.5-325/
15, 7.5-500/15
tablet: 7.5-750mg,
10-750mg
tablet: 7.5-650mg,
10-660mg, 10mg650mg
capsule, tablet: 2.5500mg, 5mg500mg, 7.5-500mg,
10mg-500mg
tablet: 5mg-325mg,
7.5-325mg, 10mg325mg
Drug Name
hydrocodone bit/
acetaminophen
(Vicodin)
Drug
Tier
2
KADIAN
3
KADIAN
5
morphine sulfate
(Kadian)
2
morphine sulfate
(Kadian)
5
morphine sulfate
(MS Contin)
2
morphine sulfate
(MS Contin)
2
morphine sulfate
(MSIR)
2
morphine sulfate
(MSIR)
2
morphine sulfate
(MSIR)
2
oxycodone hcl
(Roxicodone)
2
oxycodone hcl/
acetaminophen
(Oxycodone HCl/
acetaminophen)
2
oxycodone hcl/
acetaminophen
(Percocet)
2
14
Requirements/Limits
QL: 390
in 30
days
ST, QL:
60 in 30
days
ST, QL:
120 in 30
days
ST, QL:
60 in 30
days
ST, QL:
60 in 30
days
QL: 120
in 30
days
QL: 180
in 30
days
QL: 200
in 30
days
QL: 300
in 30
days
QL: 700
in 30
days
QL: 180
in 30
days
QL: 1800
in 30
days
QL: 180
in 30
days
tablet: 5mg-300mg,
7.5-300mg, 10mg300mg
cap er pel: 10mg
cap er pel: 200mg
cap er pel: 20mg,
30mg, 50mg, 60mg,
80mg
cap er pel: 100mg
tablet er: 30mg,
60mg, 100mg
tablet, tablet er:
15mg, 200mg
solution: 100mg/
5ml
solution: 20mg/5ml
solution: 10mg/5ml
capsule, oral conc,
tablet: 5mg, 15mg,
30mg
solution
tablet: 10mg-650mg
Drug Name
Drug
Tier
oxycodone hcl/
acetaminophen
(Percocet)
2
oxycodone hcl/
acetaminophen
(Percocet)
2
OXYCONTIN
3
OXYCONTIN
3
tramadol hcl
(Ultram ER)
2
tramadol hcl
(Ultram ER)
2
tramadol hcl
(Ultram)
2
Opiate Partial Agonists
(Buprenorphine HCl)
buprenorphine hcl
(Subutex)
buprenorphine hcl
buprenorphine hcl
(Subutex)
SUBOXONE
2
2
2
4
Requirements/Limits
QL: 240
in 30
days
QL: 360
in 30
days
capsule, tablet:
5mg-500mg, 7.5500mg
tablet: 2.5-325mg,
5mg-325mg, 7.5325mg, 10mg325mg
tab er 12h: 80mg
QL: 120
in 30
days
QL: 60 in tab er 12h: 10mg,
30 days 15mg, 20mg, 30mg,
40mg, 60mg
QL: 30 in tab er 24h: 200mg,
30 days 300mg
QL: 90 in tab er 24h: 100mg
30 days
QL: 240 tablet
in 30
days
PA, QL:
20 in 30
days
PA, QL:
5 in 30
days
PA, QL:
90 in 30
days
disp syrin
tab subl: 2mg
tab subl: 8mg
Androgens
Androgens
ANDROGEL
3
ANDROGEL
3
15
QL: 150
in 30
days
QL: 300
in 30
days
gel md pmp
gel packet
Drug Name
Drug
Tier
AXIRON
3
TESTIM
4
testosterone cypionate
(Depo-testosterone)
2
Requirements/Limits
QL: 180
in 28
days
PA, QL:
300 in 30
days
PA
Anorexigenics, Respiratory, Cerebral Stimulants
Amphetamines
amphet asp/amphet/damphet
(Adderall)
tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
(Dexedrine)
2
PA, QL: capsule er, (PA for
dextroamphetamine
120 in 30 Ages 65 and Older;
sulfate
days
May be High Risk
Med)
(Dextrostat)
2
PA, QL: tablet, (PA for
dextroamphetamine
sulfate
days
May be High Risk
Med)
Anorexigenics, Respiratory, Cerebral Stimulants, Miscellaneous
METADATE CD
4
PA, QL: (PA for Ages 65 and
30 in 30 Older; May be High
days
Risk Med)
METHYLIN
4
PA, QL: tab chew: 10mg,
180 in 30 (PA for Ages 65 and
days
Older; May be High
Risk Med)
METHYLIN
4
PA, QL: tab chew: 2.5mg,
90 in 30 5mg, (PA for Ages
days
65 and Older; May
be High Risk Med)
(Methylin)
2
PA, QL: solution, (PA for
methylphenidate hcl
days
May be High Risk
Med)
16
2
PA, QL:
60 in 30
days
Drug Name
Drug
Tier
Requirements/Limits
methylphenidate hcl
(Ritalin LA)
2
PA, QL:
30 in 30
days
methylphenidate hcl
(Ritalin LA)
2
PA, QL:
60 in 30
days
methylphenidate hcl
(Ritalin)
2
PA, QL:
90 in 30
days
NUVIGIL
4
NUVIGIL
4
RITALIN LA
4
PA, QL:
30 in 30
days
PA, QL:
90 in 30
days
PA, QL:
30 in 30
days
cpmp 50-50: 20mg,
40mg, (PA for
Ages 65 and Older;
May be High Risk
Med)
cpmp 50-50: 30mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
tablet, tablet er:
20mg, (PA for
Ages 65 and Older;
May be High Risk
Med)
tablet: 150mg,
250mg
tablet: 50mg
cpmp 50-50: 10mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
Anthelmintics
Anthelmintics
ALBENZA
STROMECTOL
3
3
Antiallergic Agents
Antiallergic Agents
ASTEPRO
3
azelastine hcl
(Astelin)
2
azelastine hcl
PATADAY
PATANASE
(Optivar)
2
3
4
PATANOL
17
3
QL: 30 in
25 days
QL: 30 in spray/pump
25 days
drops
ST
QL: 30.5
in 30
days
ST
Drug Name
Drug
Tier
Requirements/Limits
Antibacterials
Aminoglycosides
(Amikacin Sulfate)
amikacin sulfate
(Garamycin)
gentamicin sulfate
(Neomycin Sulfate)
neomycin sulfate
Antibacterials, Miscellaneous
(Cleocin HCl)
clindamycin hcl
2
(Vancocin HCl)
(Vancomycin HCl)
5
2
vancomycin hcl
vancomycin hcl
2
2
2
XIFAXAN
3
XIFAXAN
3
Cephalosporins
cefdinir
cefpodoxime proxetil
ceftriaxone sodium
cefuroxime axetil
cephalexin
Macrolides
azithromycin
(Omnicef)
(Vantin)
(Rocephin)
(Ceftin)
(Keflex)
2
2
2
2
1
(Zithromax)
2
(Biaxin)
clarithromycin
Miscellaneous B-lactam Antibiotics
(Primaxin)
imipenem/cilastatin
sodium
INVANZ
(Merrem)
meropenem
Penicillins
(Amoxil)
amoxicillin
amoxicillin/potassium clav
ampicillin trihydrate
dicloxacillin sodium
penicillin v potassium
(Augmentin)
(Ampicillin Trihydrate)
(Dicloxacillin Sodium)
(Veetids 500)
18
tablet
PA
PA, QL:
60 in 30
days
PA, QL:
9 in 30
days
capsule: 150mg,
300mg
capsule
vial, (PA for ESRD
Only)
tablet: 550mg
tablet: 200mg
tablet
GC
susp recon, tablet,
vial
2
2
4
2
1
2
1
2
1
vial
GC
capsule, susp recon,
tab chew: 125mg,
250mg; tablet
GC
GC
Drug Name
Quinolones
AVELOX ABC PACK
AVELOX
(Cipro)
ciprofloxacin hcl
(Levaquin)
levofloxacin
Sulfonamides (Systemic)
(Septra)
sulfamethoxazole/
trimethoprim
(Sulfamethoxazole/
sulfamethoxazole/
trimethoprim)
trimethoprim
(Azulfidine)
sulfasalazine
Tetracyclines
(Vibramycin)
doxycycline hyclate
minocycline hcl
(Dynacin)
Drug
Tier
3
3
1
2
1
Requirements/Limits
GC
GC
tablet
2
oral susp, vial
2
2
capsule, tablet dr,
vial
2
Anticholinergic Agents
Antimuscarinics/Antispasmodics
(Bentyl)
dicyclomine hcl
2
PA
SPIRIVA
3
QL: 30 in
30 days
capsule, syrup,
tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
Anticonvulsants
Anticonvulsants, Miscellaneous
(Depakote ER)
divalproex sodium
(Neurontin)
gabapentin
LAMICTAL (BLUE)
LAMICTAL (ORANGE)
LAMICTAL ODT
LAMICTAL XR (BLUE)
LAMICTAL XR
(GREEN)
LAMICTAL XR
(ORANGE)
LAMICTAL XR
lamotrigine
(Lamictal)
19
2
2
4
4
4
4
4
4
4
2
tab er 24: 25mg,
50mg, 100mg,
200mg, 250mg
tablet, tb chw dsp
Drug Name
levetiracetam
LYRICA
Hydantoins
DILANTIN
DILANTIN
PHENYTEK
phenytoin sodium
extended
phenytoin
Succinimides
CELONTIN
ethosuximide
(Keppra)
Drug
Tier
2
3
(Dilantin)
3
3
3
2
(Dilantin-125)
2
(Zarontin)
3
2
Requirements/Limits
QL: 93 in
31 days
capsule: 30mg
tab chew
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
JANUMET XR
3
JANUMET XR
3
JANUMET
3
JANUVIA
3
metformin hcl
(Glucophage XR)
2
metformin hcl
(Glucophage XR)
2
metformin hcl
(Glucophage)
1
metformin hcl
(Glucophage)
1
metformin hcl
(Glucophage)
1
20
QL: 30 in tbmp 24hr: 50mg30 days 500mg, 1001000mg
QL: 60 in tbmp 24hr: 5030 days 1000mg
QL: 60 in
30 days
QL: 30 in
30 days
QL: 120 tab er 24h: 500mg
in 30
days
30 days
GC, QL: tablet: 500mg
120 in 30
days
60 in 30
days
90 in 30
days
Drug Name
Drug
Tier
Requirements/Limits
PRANDIN
3
QL: 240
in 30
days
Insulins
HUMALOG
3
insuln pen
HUMALOG
3
LANTUS SOLOSTAR
3
LANTUS
3
NOVOLOG
3
NOVOLOG
3
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
GC, QL:
30 in 30
days
GC, QL:
60 in 30
days
QL: 30 in
30 days
QL: 60 in
30 days
GC, QL:
120 in 30
days
GC, QL:
60 in 30
days
tablet: 1mg, 2mg
Sulfonylureas
glimepiride
(Amaryl)
1
glimepiride
(Amaryl)
1
glipizide
(Glucotrol XL)
2
glipizide
(Glucotrol XL)
2
glipizide
(Glucotrol)
1
glipizide
(Glucotrol)
1
Thiazolidinediones
ACTOPLUS MET XR
3
ACTOPLUS MET
3
ACTOS
4
21
vial
insuln pen
vial
tablet: 4mg
tab er 24: 2.5mg,
5mg
tab er 24: 10mg
tablet: 10mg
tablet: 5mg
QL: 60 in
30 days
QL: 90 in
30 days
QL: 30 in
30 days
Drug Name
Drug
Tier
Requirements/Limits
Antidiarrhea Agents
Antidiarrhea Agents
diphenoxylate hcl/atropine (Lomotil)
loperamide hcl
(Loperamide HCl)
2
(May be High Risk
Med for Ages 65
and Older)
2
Antiemetics
5-ht3 Receptor Antagonists
(Zofran)
ondansetron hcl
(Zofran)
ondansetron hcl
ondansetron
(Zofran Odt)
2
2
PA
2
PA
vial
solution, tablet,
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
Antiemetics, Miscellaneous
(Marinol)
dronabinol
EMEND
2
3
EMEND
3
PA, QL:
2 per fill
EMEND
3
PA, QL:
3 per fill
Antihistamines (GI Drugs)
(Antivert)
meclizine hcl
prochlorperazine maleate (Compazine)
prochlorperazine maleate (Compazine)
2
1
2
PA, QL:
1 per fill
GC
capsule: 40mg,
125mg, (PA for
Part B vs Part D
Only)
capsule: 80mg, (PA
for Part B vs Part D
Only)
cap ds pk, (PA for
Part B vs Part D
Only)
tablet
supp.rect
Antifungal (Systemic)
Antifungals, Miscellaneous
(Mycostatin)
nystatin
(Lamisil)
terbinafine hcl
Azoles
(Diflucan)
fluconazole
(Diflucan)
fluconazole
(Nizoral)
ketoconazole
Echinocandins
CANCIDAS
22
2
1
1
2
2
powder(ea), tablet
GC
GC
tablet
susp recon
5
Drug Name
ERAXIS (WATER
DILUENT)
Drug
Tier
Requirements/Limits
5
Antiglaucoma Agents
Antiglaucoma Agents
ALPHAGAN P
(Alphagan P)
brimonidine tartrate
(Alphagan P)
brimonidine tartrate
(Cosopt)
dorzolamide hcl/timolol
maleat
ISTALOL
(Xalatan)
latanoprost
LUMIGAN
timolol maleate
3
2
2
2
4
2
3
(Timoptic)
2
(Xyzal)
2
(Promethazine HCl)
2
drops: 0.1%
(Drops 0.15%)
QL: 2.5
in 25
days
Antihistamines
Antihistamines
levocetirizine
dihydrochloride
promethazine hcl
PA
(PA for Ages 65 and
Older; May be High
Risk Med)
Anti-infectives (EENT)
Anti-infectives (EENT)
(Peridex)
chlorhexidine gluconate
CILOXAN
(Ciloxan)
ciprofloxacin hcl
(Romycin)
erythromycin base
MOXEZA
(Maxitrol)
neo/polymyx b sulf/
dexameth
(Oticin HC)
neomycin/polymyxin b
sulf/hc
(Floxin)
ofloxacin
TOBRADEX
(Tobradex)
tobramycin sulf/
dexamethasone
VIGAMOX
ZYMAXID
23
2
4
2
2
3
2
oint. (g)
2
2
4
2
oint. (g)
3
3
Drug Name
Drug
Tier
Requirements/Limits
Anti-infectives (Skin and Mucous Membrane)
Antibacterials (Skin and Mucous Membrane)
(Cleocin T)
clindamycin phosphate
(Vitazol)
metronidazole
(Centany)
mupirocin
Antifungals (Skin and Mucous Membrane)
(Lotrisone)
clotrimazole/
betamethasone dip
(Kuric)
ketoconazole
(Mycostatin)
nystatin
Antivirals (Skin and Mucous Membrane)
DENAVIR
ZOVIRAX
Local Anti-infectives, Miscellaneous
(Alcohol Antiseptic Pads)
alcohol antiseptic pads
(Silvadene)
silver sulfadiazine
Scabicides and Pediculicides
EURAX
(Elimite)
permethrin
2
2
2
2
2
2
cream (g), oint. (g),
powder
3
4
1
2
GC
3
2
Anti-inflammatory Agents (EENT)
Anti-inflammatory Agents (EENT)
(Flonase)
fluticasone propionate
ketorolac tromethamine
NASONEX
(Acular LS)
prednisolone acetate
RESTASIS
(Pred Forte)
2
2
3
2
4
QL: 16 in
30 days
QL: 34 in
28 days
PA, QL:
64 in 31
days
Anti-inflammatory Agents (GI Drugs)
Anti-inflammatory Agents (GI Drugs)
APRISO
ASACOL HD
ASACOL
(Colazal)
balsalazide disodium
LIALDA
PENTASA
24
3
4
4
2
4
4
Drug Name
Drug
Tier
Requirements/Limits
Anti-inflammatory Agents (Respiratory)
Anti-inflammatory Agents (Respiratory)
SINGULAIR
(Accolate)
zafirlukast
4
2
Anti-inflammatory Agents (Skin and Mucous)
Anti-inflammatory Agents (Skin and Mucous)
(Del-beta)
betamethasone
dipropionate
(Temovate)
clobetasol propionate
(Desowen)
desonide
fluocinonide
hydrocortisone
KENALOG
triamcinolone acetonide
(Fluocinonide)
(Proctocort)
(Triamcinolone Acetonide)
2
cream (g), lotion,
oint. (g)
2
2
cream (g), lotion,
oint. (g): 0.05%
2
2
4
2
aerosol
cream (g), lotion,
oint. (g): 0.025%,
0.1%, 0.5%; paste
(g)
Antilipemic Agents
Antilipemic Agents, Miscellaneous
LOVAZA
ZETIA
Bile Acid Sequestrants
(Questran)
cholestyramine (with
sugar)
WELCHOL
Fibric Acid Derivatives
(Lopid)
gemfibrozil
TRICOR
HMG-CoA Reductase Inhibitors
(Lipitor)
atorvastatin calcium
(Zocor)
simvastatin
3
4
2
3
2
4
2
1
GC, QL:
30 in 30
days
Antimigraine Agents
Selective Serotonin Agonists
(Imitrex)
sumatriptan succinate
2
(Imitrex)
2
sumatriptan succinate
25
QL: 4 in
28 days
QL: 9 in
28 days
cartridge, vial
tablet
Drug Name
Drug
Tier
ZOMIG ZMT
4
ZOMIG
4
ZOMIG
4
Requirements/Limits
QL: 9 in
28 days
QL: 6 in
28 days
QL: 9 in
28 days
spray
tablet
Antimycobacterials
Antimycobacterials
(Dapsone)
dapsone
(Isoniazid)
isoniazid
(Rifadin)
rifampin
2
2
2
Antineoplastic Agents
Antineoplastic Agents
AFINITOR
anastrozole
bicalutamide
cyclophosphamide
(Arimidex)
(Casodex)
(Cyclophosphamide)
5
2
2
2
DROXIA
ELIGARD
3
4
ELIGARD
4
ELIGARD
4
ELIGARD
5
exemestane
flutamide
GLEEVEC
(Aromasin)
(Flutamide)
hydroxyurea
JAKAFI
(Hydrea)
letrozole
LEUKERAN
(Femara)
26
2
2
5
2
5
PA, QL:
28 in 28
days
PA, ST
B vs Part D Only)
QL: 1 in
112 days
QL: 1 in
28 days
QL: 1 in
84 days
QL: 1 in
168 days
disp syrin: 30mg
disp syrin: 7.5mg
disp syrin: 22.5mg
disp syrin: 45mg
QL: 60 in
30 days
PA, QL:
60 in 30
days
2
4
Drug Name
leuprolide acetate
(Lupron)
Drug
Tier
2
LUPRON DEPOT
5
LUPRON DEPOT
5
LUPRON DEPOT
5
LUPRON DEPOT
5
LUPRON DEPOT-PED
5
MEGACE ES
3
megestrol acetate
(Megace)
2
mercaptopurine
methotrexate sodium
(Purinethol)
(Methotrexate Sodium)
2
1
methotrexate sodium
(Methotrexate Sodium)
1
NEXAVAR
5
NILANDRON
SPRYCEL
SUTENT
3
5
5
tamoxifen citrate
TARCEVA
(Nolvadex)
2
5
TARGRETIN
TASIGNA
TREXALL
5
5
3
TYKERB
5
27
Requirements/Limits
QL: 2 in
28 days
QL: 1 in
112 days
QL: 1 in
168 days
QL: 1 in
28 days
QL: 1 in
84 days
QL: 1 in
28 days
syringekit: 30mg
syringekit: 45mg
syringekit: 3.75mg
syringekit:
11.25mg, 22.5mg
(May be High Risk
Med for Ages 65
and Older)
(May be High Risk
Med for Ages 65
and Older)
GC, PA,
ST
GC, PA
B vs Part D Only)
vial, (PA for Part B
vs Part D Only)
PA, QL:
120 in 30
days
PA, QL:
30 in 30
days
PA, QL:
30 in 30
days
PA, ST
(PA for Part B vs
Part D Only)
Drug Name
Drug
Tier
VOTRIENT
5
ZYTIGA
5
Requirements/Limits
PA, QL:
120 in 30
days
PA, QL:
120 in 30
days
Antiparkinsonian Agents
Antiparkinsonian Agents
(Benztropine Mesylate)
benztropine mesylate
1
GC, PA
PA
benztropine mesylate
(Cogentin)
2
carbidopa/levodopa
pramipexole di-hcl
ropinirole hcl
(Sinemet 25-100)
(Mirapex)
(Requip)
2
2
2
tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
ampul, (PA for
Ages 65 and Older;
May be High Risk
Med)
Antiprotozoal Agents
Antiprotozoal Agents
atovaquone/proguanil hcl (Malarone)
(Plaquenil)
hydroxychloroquine
sulfate
MEPRON
(Flagyl)
metronidazole
2
2
tablet: 250-100mg
5
2
Antipruritics and Local Anesthetics
Antipruritics and Local Anesthetics
(Lidocaine)
lidocaine
lidocaine/prilocaine
(EMLA)
LIDODERM
2
PA
2
PA
(PA for ESRD
Only)
(PA for ESRD
Only)
4
Antiulcer Agents
Antiulcer Agents
omeprazole
pantoprazole sodium
PROTONIX IV
(Prilosec)
2
(Protonix)
2
4
28
capsule dr: 10mg,
20mg, 40mg, (Rx
Product Only)
Drug Name
Drug
Tier
ranitidine hcl
(Taladine)
2
ranitidine hcl
(Zantac)
1
Requirements/Limits
capsule, syrup, vial,
(Rx Product Only)
tablet, (Rx Product
Only)
GC
Antivirals (Systemic)
Antiretrovirals
ATRIPLA
EPZICOM
ISENTRESS
NORVIR
PREZISTA
PREZISTA
5
5
5
4
3
5
REYATAZ
REYATAZ
3
5
TRUVADA
VIREAD
Antivirals, Miscellaneous
RELENZA
TAMIFLU
5
5
4
3
Hcv Protease Inhibitors
INCIVEK
5
VICTRELIS
5
Interferons
PEGASYS PROCLICK
PEGASYS
PEGINTRON REDIPEN
PEGINTRON
SYLATRON
5
5
5
5
5
Nucleosides and Nucleotides
(Zovirax)
acyclovir
(Famvir)
famciclovir
2
2
29
tablet: 75mg
tablet: 150mg,
400mg, 600mg
capsule: 100mg
capsule: 150mg,
200mg, 300mg
capsule, susp recon:
6mg/ml
PA, QL:
168 in 28
days
PA, QL:
336 in 28
days
PA
PA
PA
PA
PA, QL:
1 in 28
days
kit: 50mcg/0.5
Drug Name
valacyclovir hcl
(Valtrex)
Drug
Tier
Requirements/Limits
2
Anxiolytics, Sedatives and Hypnotics
Anxiolytics, Sedatives and Hypnotics, Miscellaneous
(Hydroxyzine HCl)
hydroxyzine hcl
2
(Ambien)
2
Benzodiazepines
alprazolam
(Xanax XR)
2
alprazolam
(Xanax XR)
2
alprazolam
(Xanax)
2
clonazepam
(Klonopin)
2
clonazepam
(Klonopin)
2
diazepam
diazepam
(Diastat)
(Diazepam)
2
2
diazepam
(Valium)
2
zolpidem tartrate
PA
(PA for Ages 65 and
Older; May be High
Risk Med)
PA, QL: (PA/QL for Ages 65
90 in 365 and Older; May be
days
High Risk Med)
Benzodiazepines
QL: 30 in
30 days
QL: 60 in
30 days
QL: 90 in
30 days
QL: 300
in 30
days
QL: 90 in
30 days
tab er 24h: 0.5mg,
1mg
tab er 24h: 2mg,
3mg
tab rapdis, tablet
tab rapdis: 2mg;
tablet: 2mg
tab rapdis: 0.125mg,
0.25mg, 0.5mg,
1mg; tablet: 0.5mg,
1mg
kit
PA, QL: oral conc, solution,
1200 in (PA for Ages 65 and
30 days Older; May be High
Risk Med)
PA, QL: tablet, (PA for
days
May be High Risk
Med)
Beta-Adrenergic Blocking Agents
Beta-Adrenergic Blocking Agents
(Tenormin)
atenolol
(Coreg)
carvedilol
INNOPRAN XL
(Toprol XL)
metoprolol succinate
(Lopressor)
metoprolol tartrate
30
1
1
4
2
1
GC
GC
GC
tablet
Drug Name
metoprolol tartrate
propranolol hcl
(Metoprolol Tartrate)
(Propranolol HCl)
Drug
Tier
Requirements/Limits
2
2
vial
2
various dosage and/
or strengths are
available
tablet
tablet
cap24h pct, cap24h
pel: 120mg, 180mg,
240mg; tablet er,
vial
Calcium-Channel Blocking Agents
Calcium-Channel Blocking Agents, Miscellaneous
(Cardizem CD)
diltiazem hcl
diltiazem hcl
verapamil hcl
verapamil hcl
(Cardizem)
(Calan)
(Calan)
Dihydropyridines
(Norvasc)
amlodipine besylate
(Lotrel)
amlodipine besylate/
benazepril
(Procardia XL)
nifedipine
1
1
2
GC
GC
1
2
GC
2
tab er 24, tablet er
Caloric Agents
Caloric Agents
AMINOSYN II
3
PA
AMINOSYN II
3
PA
AMINOSYN II
3
PA
AMINOSYN II
3
PA
AMINOSYN M
3
PA
AMINOSYN
3
PA
AMINOSYN-HBC
3
PA
31
iv soln: 10%, (PA
Only)
iv soln: 15%, (PA
Only)
iv soln: 7%, (PA
Only)
iv soln: 8.5%, (PA
Only)
(PA for Part B vs
Part D Only)
iv soln: 8.5%, (PA
Only)
(PA for Part B vs
Part D Only)
Drug Name
Drug
Tier
Requirements/Limits
AMINOSYN-PF
3
PA
AMINOSYN-PF
3
PA
CLINIMIX E
3
PA
CLINIMIX E
3
PA
CLINIMIX E
3
PA
CLINIMIX
3
PA
CLINIMIX
3
PA
CLINIMIX
3
PA
CLINISOL
3
PA
dextrose 10 % and 0.225
% nacl
dextrose 10%-0.5 normal
saline
dextrose 10%-water
(Dextrose 10 % and 0.225 %
NaCl)
(Dextrose 10%-0.5 Normal
Saline)
(Dextrose 10%-water)
dextrose 2.5%-0.5normal
saline
dextrose 5 % and 0.33 %
nacl
nacl
dextrose 5 %-0.225 %
nacl
dextrose 5 %-0.45 % nacl
(Dextrose 2.5%-0.5 Normal
Saline)
(Dextrose 5 % and 0.33 % NaCl)
2
(Dextrose 5 % and 0.9 % NaCl)
2
(Dextrose 5 %-0.225 % NaCl)
2
(Dextrose 5 %-0.45 % NaCl)
2
32
2
iv soln: 10%, (PA
Only)
iv soln: 7%, (PA
Only)
iv soln: 2.75%, (PA
Only)
iv soln: 4.25%, (PA
Only)
iv soln: 5%, (PA
Only)
iv soln: 2.75%, (PA
Only)
iv soln: 4.25%, (PA
Only)
iv soln: 5%, (PA
Only)
(PA for Part B vs
Part D Only)
dehp fr bg
2
2
PA
(PA for Part B vs
Part D Only)
2
Drug Name
Requirements/Limits
2
3
PA
3
PA
HEPATAMINE
3
PA
HEPATASOL
3
PA
INTRALIPID
3
PA
LIPOSYN III
3
PA
NEPHRAMINE
3
PA
PREMASOL
3
PA
PREMASOL
3
PA
PROCALAMINE
3
PA
PROSOL
3
PA
TRAVASOL
3
PA
TROPHAMINE
3
PA
TROPHAMINE
3
PA
dextrose 5 %-water
FREAMINE III with
ELECTROLYTES
FREAMINE III
(Dextrose 5 %-water)
Drug
Tier
(PA for Part B vs
Part D Only)
iv soln: 8.5%, (PA
Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
emulsion: 20%,
30%, (PA for Part
B vs Part D Only)
emulsion: 10%,
20%, (PA for Part
B vs Part D Only)
(PA for Part B vs
Part D Only)
iv soln: 10%, (PA
Only)
iv soln: 6%, (PA
Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
iv soln: 10%, (PA
Only)
iv soln: 10%, (PA
Only)
iv soln: 6%, (PA
Only)
Cardiac Drugs
Antiarrhythmic Agents
(Cordarone)
amiodarone hcl
(Tambocor)
flecainide acetate
33
2
2
tablet, vial
Drug Name
MULTAQ
Cardiac Drugs, Miscellaneous
(Lanoxin)
digoxin
Drug
Tier
Requirements/Limits
3
2
PA, QL:
30 in 30
days
2
PA
DIGOXIN
3
RANEXA
3
RANEXA
3
PA, QL:
75 in 30
days
QL: 120
in 30
days
30 days
digoxin
(Lanoxin)
tablet, (PA/QL for
Ages 65 and Older;
May be High Risk
Med)
ampul, (PA for
Ages 65 and Older;
May be High Risk
Med)
(PA/QL for Ages 65
and Older; May be
High Risk Med)
tab er 12h: 500mg
Cathartics and Laxatives
Cathartics and Laxatives
polyethylene glycol 3350 (Polyethylene Glycol 3350)
sodium chloride/nahco3/ (Nulytely)
kcl/peg
2
2
Cell Stimulants and Proliferants
Cell Stimulants and Proliferants
RETIN-A MICRO
(Retin-A)
tretinoin
4
2
PA
PA
Central Nervous System Agents, Miscellaneous
Central Nervous System Agents, Miscellaneous
(Eskalith)
lithium carbonate
NAMENDA
2
3
NAMENDA
3
NAMENDA
3
primidone
SAVELLA
(Mysoline)
34
2
3
QL: 360 solution
in 30
days
QL: 49 in tab ds pk
28 days
QL: 62 in tablet
31 days
QL: 60 in
30 days
Drug Name
Drug
Tier
Requirements/Limits
Contraceptives
Contraceptives
levonorgestrel-eth
estradiol
levonorgestrel-eth
estradiol
noreth a-et estra/fe
fumarate
norethindrone-ethinyl
estrad
norgestimate-ethinyl
estradiol
(Lybrel)
2
(Seasonale)
2
(Loestrin Fe)
2
(Ovcon-35)
2
(Ortho Tri-cyclen)
2
tablet
QL: 91 in tbdspk 3mo
84 days
Devices
Devices
needles, insulin disposable (Needles, Insulin Disposable)
(Syring W-ndl,disp,insul,0.5ml)
syring wndl,disp,insul,0.5ml
2
2
Diuretics
Diuretics, Miscellaneous
(Chlorthalidone)
chlorthalidone
(Hydrochlorothiazide)
hydrochlorothiazide
Loop Diuretics
(Furosemide)
furosemide
(Lasix)
furosemide
(Demadex)
torsemide
Potassium-sparing Diuretics
(Amiloride/hydrochlorothiazide)
amiloride/
hydrochlorothiazide
(Maxzide-25mg)
triamterene/
hydrochlorothiazid
1
1
GC
GC
2
1
2
GC
1
GC
1
GC
EENT Drugs, Miscellaneous
(Atrovent)
ipratropium bromide
2
ipratropium bromide
(Atrovent)
2
QL: 15 in spray: 42mcg
10 days
QL: 30 in spray: 21mcg
28 days
naphazoline hcl
(Albalon)
2
solution, vial
tablet
EENT Drugs, Miscellaneous
Enzymes
Enzymes
ADAGEN
35
5
Drug Name
Drug
Tier
ALDURAZYME
CEREZYME
ELAPRASE
ELITEK
FABRAZYME
LUMIZYME
MYOZYME
NAGLAZYME
PULMOZYME
5
5
5
5
5
5
5
5
5
VPRIV
5
Requirements/Limits
PA
(PA for Part B vs
Part D Only)
PA, QL:
8 in 28
days
PA
PA, QL:
4 in 28
days
(PA for Ages 65 and
Older; May be High
Risk Med)
cream/appl
patch tdwk, (PA for
Ages 65 and Older;
May be High Risk
Med)
tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
Estrogens and Antiestrogens
Estrogens and Antiestrogens
ALORA
4
ESTRACE
estradiol
(Climara)
3
2
estradiol
(Estrace)
2
PA
ESTRING
4
PA, QL:
1 in 84
days
EVISTA
PREMARIN
PREMARIN
3
3
3
PA
PA
PREMPHASE
3
PA
PREMPRO
3
PA
36
(PA for Ages 65 and
Older; May be High
Risk Med)
(PA for Ages 65 and
Older; May be High
Risk Med)
(PA for Ages 65 and
Older; May be High
Risk Med)
Drug Name
Drug
Tier
VAGIFEM
3
VIVELLE-DOT
3
Requirements/Limits
PA, QL:
18 in 28
days
PA, QL:
8 in 28
days
tablet: 10mcg
(PA for Ages 65 and
Older; May be High
Risk Med)
Genitourinary Smooth Muscle Relaxants
Genitourinary Smooth Muscle Relaxants
GELNIQUE
oxybutynin chloride
oxybutynin chloride
VESICARE
(Ditropan XL)
(Ditropan)
4
2
1
3
QL: 30 in gel packet
30 days
syrup, tab er 24
GC
tablet
GI Drugs, Miscellaneous
GI Drugs, Miscellaneous
CREON
(Metoclopramide HCl)
metoclopramide hcl
metoclopramide hcl
(Reglan)
PANCREAZE
ZENPEP
3
2
PA
1
GC, PA
solution, vial, (PA
for Ages 65 and
Older; May be High
Risk Med)
tablet, (PA for
Ages 65 and Older;
May be High Risk
Med)
4
3
Heavy Metal Antagonists
Heavy Metal Antagonists
EXJADE
EXJADE
3
5
FERRIPROX
5
tab disper: 125mg
tab disper: 250mg,
500mg
Hematologic Agents
Anticoagulants
enoxaparin sodium
(Lovenox)
2
enoxaparin sodium
(Lovenox)
2
37
QL: 13.6
in 30
days
QL: 18 in
30 days
disp syrin: 40mg/
0.4ml
disp syrin: 30mg/
0.3ml
Drug Name
Drug
Tier
enoxaparin sodium
(Lovenox)
2
enoxaparin sodium
(Lovenox)
2
enoxaparin sodium
(Lovenox)
5
enoxaparin sodium
(Lovenox)
5
enoxaparin sodium
(Lovenox)
5
LOVENOX
3
PRADAXA
4
(Coumadin)
warfarin sodium
Hematologic Agents, Miscellaneous
(Agrylin)
anagrelide hcl
(Trental)
pentoxifylline
Platelet-aggregation Inhibitors
(Pletal)
cilostazol
EFFIENT
1
Requirements/Limits
QL: 20.4
in 30
days
QL: 27.2
in 30
days
QL: 27.2
in 30
days
QL: 34 in
30 days
QL: 36 in
30 days
QL: 36 in
30 days
PA, QL:
60 in 30
days
GC
disp syrin: 60mg/
0.6ml
disp syrin: 80mg/
0.8ml
disp syrin: 120mg/
.8ml
disp syrin: 150mg/
ml
disp syrin: 100mg/
ml
vial
2
2
2
3
QL: 30 in
30 days
Hematopoietic Agents
Hematopoietic Agents
ARANESP
3
ARANESP
3
ARANESP
3
ARANESP
3
38
PA, QL:
1.2 in 28
days
PA, QL:
1.6 in 28
days
PA, QL:
1.68 in
28 days
PA, QL:
4 in 28
days
disp syrin: 60mcg/
0.3
disp syrin: 40mcg/
0.4
disp syrin: 25mcg/
0.42
vial: 25mcg/ml,
40mcg/ml, 60mcg/
ml
Drug Name
Drug
Tier
ARANESP
5
ARANESP
5
ARANESP
5
ARANESP
5
ARANESP
5
EPOGEN
3
PROCRIT
3
PROCRIT
5
PROCRIT
5
Requirements/Limits
PA, QL:
1.2 in 28
days
PA, QL:
1.6 in 28
days
PA, QL:
2 in 28
days
PA, QL:
2.4 in 28
days
PA, QL:
4 in 28
days
PA, QL:
12 in 28
days
PA, QL:
12 in 28
days
PA, QL:
12 in 28
days
PA, QL:
6 in 28
days
disp syrin: 150mcg/
0.3
disp syrin: 200mcg/
0.4
disp syrin: 100mcg/
0.5
disp syrin: 300mcg/
0.6
disp syrin: 500mcg/
ml; vial: 100mcg/
ml, 200mcg/ml,
300mcg/ml
vial: 2000/ml, 3000/
ml, 4000/ml, 10000/
ml, 20000/ml
vial: 2000/ml, 3000/
ml, 4000/ml, 10000/
ml
vial: 20000/ml
vial: 40000/ml
Hypotensive Agents
Hypotensive Agents, Miscellaneous
(Catapres)
clonidine hcl
(Apresoline)
hydralazine hcl
1
2
GC
Ion-Removing Agents
Ion-Removing Agents
(Phoslo)
calcium acetate
PHOSLYRA
RENVELA
39
2
4
3
powd pack: 2.4g;
tablet
Drug Name
Drug
Tier
Requirements/Limits
Irrigating Solutions
Irrigating Solutions
(Sodium Chloride Irrig Solution)
sodium chloride irrig
solution
water for irrigation,sterile (Water for Irrigation, Sterile)
2
2
Local Anesthetics
Local Anesthetics
(Xylocaine)
lidocaine hcl
2
lidocaine hcl
(Xylocaine)
2
proparacaine hcl
(Ophthetic)
2
jel (ml), jel/pf app,
solution
vial, (PA for ESRD
Only)
PA
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTONEL
3
ACTONEL
3
ACTONEL
3
alendronate sodium
(Fosamax)
1
alendronate sodium
(Fosamax)
1
allopurinol
ATELVIA
(Zyloprim)
1
4
AVODART
AVONEX
ADMINISTRATION
PACK
AVONEX
azathioprine
QL: 1 in
28 days
QL: 31 in
31 days
QL: 4 in
28 days
GC, QL:
4 in 28
days
GC
ST
5
2
ST
PA
CELLCEPT
5
PA
COLCRYS
COPAXONE
3
5
40
tablet: 5mg, 30mg
tablet: 35mg
tablet: 35mg, 70mg
tablet: 5mg, 10mg,
40mg
GC
QL: 4 in
28 days
3
5
(Imuran)
tablet: 150mg
(PA for Part B vs
Part D Only)
susp recon, (PA for
Part B vs Part D
Only)
Drug Name
Drug
Tier
ELMIRON
ENBREL
3
5
ENBREL
5
ENBREL
5
finasteride
GLUCAGEN
GLUCAGON
EMERGENCY KIT
HUMIRA
(Proscar)
5
leflunomide
mycophenolate mofetil
(Arava)
(Cellcept)
2
2
probenecid
REBIF
REVLIMID
(Probenecid)
2
5
5
SENSIPAR
SENSIPAR
ULORIC
PA, QL:
7.84 in
28 days
PA, QL:
8 in 28
days
PA, QL:
8.16 in
28 days
pen injctr
PA, QL:
4 in 28
days
PA, QL:
6 in 28
days
kit, pen ij kit: 40mg/
0.8ml
PA
(PA for Part B vs
Part D Only)
kit
disp syrin
2
3
3
5
HUMIRA
Requirements/Limits
3
5
3
pen ij kit: 40mg/
0.8ml, (Starter Kit)
LA, QL:
30 in 30
days
tablet: 30mg
tablet: 60mg, 90mg
ST, QL:
31 in 31
days
Opiate Antagonists
Opiate Antagonists
(Naloxone HCl)
naloxone hcl
(Revia)
naltrexone hcl
41
2
2
disp syrin: 1mg/ml
Drug Name
Drug
Tier
Requirements/Limits
Parasympathomimetics (Cholinergic Agents)
Parasympathomimetics (Cholinergic Agents)
ARICEPT
donepezil hcl
(Aricept)
EXELON
3
2
4
galantamine hbr
(Razadyne ER)
2
galantamine hbr
(Razadyne)
2
galantamine hbr
(Razadyne)
2
Parathyroid
calcitonin,salmon,syntheti (Miacalcin)
c
2
FORTEO
4
FORTICAL
3
MIACALCIN
3
PA, QL:
31 in 31
days
QL: 31 in
31 days
PA, QL:
30 in 30
days
QL: 30 in
30 days
QL: 200
in 30
days
QL: 60 in
30 days
tablet: 23mg
patch td24
cap24h pel
solution
tablet
Parathyroid
QL: 3.7
in 28
days
QL: 3 in
28 days
QL: 3.7
in 28
days
PA
vial, (PA for ESRD
Only)
Pituitary
Pituitary
desmopressin acetate
desmopressin acetate
(DDAVP)
(Desmopressin Acetate)
2
2
GENOTROPIN
3
GENOTROPIN
5
HUMATROPE
5
42
ampul, tablet
QL: 15 in spray/pump
30 days
PA
disp syrin: 0.2mg/
0.25
PA
various dosage and/
or strengths are
available
PA
Drug Name
NORDITROPIN
FLEXPRO
NORDITROPIN
NORDIFLEX
NUTROPIN AQ NUSPIN
NUTROPIN AQ
NUTROPIN
OMNITROPE
Drug
Tier
Requirements/Limits
5
PA
5
PA
5
5
5
3
PA
PA
PA
PA
OMNITROPE
5
PA
SAIZEN
SEROSTIM
STIMATE
TEV-TROPIN
ZORBTIVE
5
5
4
3
5
PA
PA
cartridge: 5mg/2ml
cartridge: 10mg/
1.5ml
cartridge: 5mg/
1.5ml; vial
cartridge, vial: 5mg
PA
PA
Progestins
Progestins
DEPO-PROVERA
medroxyprogesterone
acetate
medroxyprogesterone
acetate
norethindrone acetate
3
(Depo-provera)
2
(Provera)
2
(Aygestin)
2
QL: 10 in vial: 400mg/ml
28 days
QL: 1 in vial
84 days
tablet
Psychotherapeutic Agents
Antidepressants
citalopram hydrobromide
citalopram hydrobromide
CYMBALTA
(Celexa)
1
(Celexa)
2
3
CYMBALTA
3
fluoxetine hcl
(Prozac)
1
fluoxetine hcl
mirtazapine
paroxetine hcl
(Prozac)
(Remeron)
(Paxil CR)
2
2
2
43
GC, QL: tablet
30 in 30
days
solution
QL: 30 in capsule dr: 30mg
30 days
QL: 60 in capsule dr: 20mg,
30 days 60mg
GC
capsule, tablet:
10mg, 20mg
capsule dr, solution
tab er 24h
Drug Name
Drug
Tier
(Paxil)
paroxetine hcl
PAXIL
(Zoloft)
sertraline hcl
(Zoloft)
sertraline hcl
(Trazodone HCl)
trazodone hcl
VENLAFAXINE HCL
ER
(Effexor XR)
venlafaxine hcl
Antipsychotic Agents
ABILIFY DISCMELT
1
4
1
2
1
2
ABILIFY DISCMELT
3
ABILIFY
3
ABILIFY
3
ABILIFY
3
GC
tablet
oral susp
tablet
oral conc
GC
GC
2
3
clozapine
(Clozaril)
2
clozapine
(Clozaril)
2
clozapine
(Clozaril)
2
FAZACLO
4
FAZACLO
4
FAZACLO
4
44
Requirements/Limits
ST, QL:
62 in 31
days
ST, QL:
93 in 31
days
ST, QL:
161.2 in
28 days
ST, QL:
31 in 31
days
ST, QL:
930 in 31
days
QL: 140
in 31
days
QL: 279
in 31
days
QL: 93 in
31 days
ST, QL:
124 in 31
days
ST, QL:
186 in 31
days
ST, QL:
93 in 31
days
tab rapdis: 15mg
tab rapdis: 10mg
vial
tablet
solution
tablet: 200mg
tablet: 100mg
tablet: 25mg, 50mg
tab rapdis: 200mg
tab rapdis: 150mg
tab rapdis: 12.5mg,
25mg, 100mg
Drug Name
Drug
Tier
haloperidol
olanzapine
(Haloperidol)
(Zyprexa)
2
2
perphenazine
quetiapine fumarate
(Perphenazine)
(Seroquel)
1
2
risperidone
(Risperdal M-tab)
2
risperidone
(Risperdal)
2
risperidone
(Risperdal)
2
SEROQUEL XR
4
SEROQUEL XR
4
ZYPREXA
4
Requirements/Limits
QL: 31 in
31 days
GC
QL: 93 in
31 days
QL: 124
in 31
days
QL: 496
in 31
days
QL: 62 in
31 days
ST, QL:
31 in 31
days
ST, QL:
62 in 31
days
QL: 31 in
31 days
tab rapdis: 3mg,
4mg
solution
tab rapdis: 0.25mg,
0.5mg, 1mg, 2mg;
tablet
tab er 24h: 200mg
tab er 24h: 50mg,
150mg, 300mg,
400mg
vial
Renin-Angiotensin-Aldosterone System Inhibitors
Angiotensin II Receptor Antagonists
DIOVAN HCT
DIOVAN
(Cozaar)
losartan potassium
(Hyzaar)
losartan/
hydrochlorothiazide
Angiotensin-Converting Enzyme Inhibitors
(Lotensin)
benazepril hcl
(Vasotec)
enalapril maleate
(Zestril)
lisinopril
(Prinzide)
lisinopril/
hydrochlorothiazide
(Altace)
ramipril
Renin-Angiotensin-Aldosterone System Inhibitors
(Aldactazide)
spironolact/
hydrochlorothiazid
45
4
4
1
2
ST
ST
GC
1
1
1
1
GC
GC
GC
GC
1
GC
2
Drug Name
spironolactone
(Aldactone)
Drug
Tier
Requirements/Limits
2
Replacement Preparations
Replacement Preparations
(0.9 % Sodium Chloride)
0.9 % sodium chloride
(Dextrose 5%-Lactated Ringers)
dextrose 5%-lactated
ringers
IONOSOL B with
DEXTROSE 5%
IONOSOL MBDEXTROSE 5%
ISOLYTE H W/
DEXTROSE
ISOLYTE M W/
DEXTROSE
ISOLYTE P with
DEXTROSE
ISOLYTE S with
DEXTROSE
ISOLYTE S
LACTATED RINGERS
NORMOSOL-M and
DEXTROSE
NORMOSOL-R PH 7.4
PLASMA-LYTE 148
PLASMA-LYTE 56 IN
DEXTROSE
PLASMA-LYTE A PH
7.4
(Potassium Chlorid/d5potassium chlorid/d50.225NaCl)
0.225nacl
(Potassium Chloride In
potassium chloride in
0.9%NaCl)
0.9%nacl
(K-dur)
potassium chloride
potassium chloride/d50.33nacl
potassium chloride/d50.45nacl
(Potassium Chloride/d50.33NaCl)
(Potassium Chloride/d50.45NaCl)
46
2
2
3
3
3
3
3
3
3
4
3
3
3
3
3
2
iv soln: 20meq/l
2
2
capsule er,
piggyback, tab er
prt, tablet er, vial
2
2
Drug Name
Drug
Tier
potassium chloride/d50.9%nacl
potassium chloride/d5lr
potassium chloride/d5w
(Potassium Chloride/d50.9%NaCl)
(Potassium Chloride/D5 LR)
(Potassium Chloride/D5W)
2
potassium chloride-0.45%
nacl
ringers solution
sodium chloride 0.45 %
sodium chloride 3%
sodium chloride 5%
sodium chloride
TPN ELECTROLYTES
(Potassium Chloride-0.45%
NaCl)
(Ringers Solution)
(Sodium Chloride 0.45 %)
(Sodium Chloride 3%)
(Sodium Chloride 5%)
(Sodium Chloride)
2
Requirements/Limits
2
2
iv soln: 20meq/l,
30meq/l, 40meq/l
2
2
2
2
2
3
iv soln
Respiratory Tract Agents, Miscellaneous
Respiratory Tract Agents, Miscellaneous
DALIRESP
theophylline anhydrous
(Theochron)
3
ST, QL:
30 in 30
days
2
elixir, tab er 12h:
100mg, 200mg,
300mg, 450mg;
tablet er
Serums
Serums
CARIMUNE NF
NANOFILTERED
GAMMAGARD LIQUID
5
PA
5
PA
GAMMAPLEX
5
PA
GAMUNEX-C
5
PA
HIZENTRA
5
PA
PRIVIGEN
5
PA
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
(PA for Part B vs
Part D Only)
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
(Baclofen)
baclofen
47
2
Drug Name
cyclobenzaprine hcl
Drug
Tier
(Flexeril)
2
Requirements/Limits
PA
tablet: 5mg, 10mg,
(PA for Ages 65 and
Older; May be High
Risk Med)
Skin and Mucous Membrane Agents, Miscellaneous
Skin and Mucous Membrane Agents, Miscellaneous
(Lac-hydrin)
ammonium lactate
CARAC
ELIDEL
FLUOROPLEX
(Efudex)
fluorouracil
(Aldara)
imiquimod
2
3
3
3
2
2
PROTOPIC
SANTYL
ZYCLARA
4
3
3
PA
cream (g)
PA, QL:
24 in 30
days
PA
PA, QL:
28 in 28
days
Somatotropin Agonists and Antagonists
Somatotropin Agonists and Antagonists
INCRELEX
SOMAVERT
5
5
Sympatholytic Adrenergic Blocking Agents
(Uroxatral)
alfuzosin hcl
(Flomax)
tamsulosin hcl
2
2
Sympathomimetic (Adrenergic) Agents
Sympathomimetic (Adrenergic) Agents
(Accuneb)
albuterol sulfate
albuterol sulfate
(Proventil)
COMBIVENT
48
2
PA
solution, vial-neb:
0.63mg/3ml,
1.25mg/3ml, 2.5mg/
3ml, (PA for Part B
vs Part D Only)
syrup, tab er 12h,
tablet
2
3
QL: 29.4
in 30
days
Drug Name
Drug
Tier
PROAIR HFA
3
SEREVENT DISKUS
3
VENTOLIN HFA
4
Requirements/Limits
QL: 17 in
25 days
QL: 62 in
31 days
QL: 36 in
25 days
Thyroid and Antithyroid Agents
Thyroid and Antithyroid Agents
(Synthroid)
levothyroxine sodium
(Tapazole)
methimazole
1
2
GC
tablet
tablet: 5mg, 10mg
Toxoids
Toxoids
ADACEL
BOOSTRIX
TETANUS DIPHTHERIA
TOXOIDS
3
3
3
vial
Urinary Anti-infectives
Urinary Anti-infectives
(Macrobid)
nitrofurantoin
macrocrystal
trimethoprim
(Trimethoprim)
2
PA, QL: (PA/QL for Ages 65
90 in 365 and Older; May be
days
High Risk Med)
2
Vaccines
Vaccines
HAVRIX
3
MENACTRA
MENVEO A-C-Y-W-135DIP
TWINRIX
TYPHIM VI
VAQTA
3
3
3
ZOSTAVAX
3
PA
(PA for Part B vs
Part D Only)
vial
3
3
vial
PA
vial, (PA for Part B
vs Part D Only)
Vasodilating Agents
Vasodilating Agents
AGGRENOX
isosorbide mononitrate
(Imdur)
49
3
2
QL: 60 in
30 days
tab er 24h, tablet:
20mg
Drug Name
Drug
Tier
NITRO-BID
nitroglycerin
(Nitro-dur)
3
2
nitroglycerin
(Nitro-dur)
2
nitroglycerin
NITROSTAT
(Nitroglycerin)
2
3
Requirements/Limits
QL: 30 in patch td24: 0.1mg/
30 days hr, 0.2mg/hr, 0.6mg/
hr
QL: 60 in patch td24: 0.4mg/
30 days hr
vial
Vitamins and Minerals
Vitamins and Minerals
(Rocaltrol)
calcitriol
pnv with ca,no.72/iron/fa
(Pnv with Ca,no.72/iron/fa)
50
2
3
PA
(PA for ESRD
Only)
(All Pre-Natal
Vitamins are
Covered)
INDEX
0.9 % sodium chloride ....... 46
ABILIFY............................ 44
ABILIFY DISCMELT....... 44
acetaminophen with codeine
........................................ 13
ACTONEL......................... 40
ACTOPLUS MET ............. 21
ACTOPLUS MET XR....... 21
ACTOS .............................. 21
acyclovir............................. 29
ADACEL ........................... 49
ADAGEN........................... 35
ADVAIR DISKUS............. 12
ADVAIR HFA ................... 12
AFINITOR......................... 26
AGGRENOX ..................... 49
ALBENZA......................... 17
albuterol sulfate ................. 48
alcohol antiseptic pads ...... 24
ALDURAZYME................ 36
alendronate sodium............ 40
alfuzosin hcl ....................... 48
allopurinol.......................... 40
ALORA.............................. 36
ALPHAGAN P .................. 23
alprazolam ......................... 30
amikacin sulfate ................. 18
amiloride/
hydrochlorothiazide ....... 35
AMINOSYN ...................... 31
AMINOSYN II .................. 31
AMINOSYN M ................. 31
AMINOSYN-HBC ............ 31
AMINOSYN-PF ................ 32
amiodarone hcl .................. 33
amlodipine besylate ........... 31
amlodipine besylate/
benazepril....................... 31
ammonium lactate.............. 48
amoxicillin.......................... 18
amoxicillin/potassium clav. 18
amphet asp/amphet/d-amphet
........................................16
ampicillin trihydrate...........18
anagrelide hcl.....................38
anastrozole .........................26
ANDROGEL......................15
APRISO..............................24
ARANESP....................38, 39
ARICEPT ...........................42
ASACOL............................24
ASACOL HD .....................24
ASTEPRO ..........................17
ATELVIA...........................40
atenolol...............................30
atorvastatin calcium...........25
atovaquone/proguanil hcl ..28
ATRIPLA ...........................29
AVELOX ...........................19
AVELOX ABC PACK.......19
AVODART ........................40
AVONEX ...........................40
AVONEX
ADMINISTRATION
PACK .............................40
AXIRON ............................16
azathioprine........................40
azelastine hcl ......................17
azithromycin .......................18
baclofen ..............................47
balsalazide disodium ..........24
benazepril hcl .....................45
benztropine mesylate ..........28
betamethasone dipropionate
........................................25
bicalutamide .......................26
BOOSTRIX........................49
brimonidine tartrate ...........23
BUPHENYL.......................12
buprenorphine hcl ..............15
calcitonin,salmon,synthetic 42
calcitriol .............................50
I-1
calcium acetate .................. 39
CANCIDAS....................... 22
CARAC ............................. 48
carbidopa/levodopa ........... 28
CARIMUNE NF
NANOFILTERED......... 47
carvedilol ........................... 30
cefdinir............................... 18
cefpodoxime proxetil.......... 18
ceftriaxone sodium............. 18
cefuroxime axetil................ 18
CELEBREX....................... 13
CELLCEPT ....................... 40
CELONTIN ....................... 20
cephalexin.......................... 18
CEREZYME...................... 36
chlorhexidine gluconate .... 23
chlorthalidone.................... 35
cholestyramine (with sugar)
....................................... 25
cilostazol............................ 38
CILOXAN ......................... 23
ciprofloxacin hcl .......... 19, 23
citalopram hydrobromide .. 43
clarithromycin ................... 18
clindamycin hcl.................. 18
clindamycin phosphate ...... 24
CLINIMIX......................... 32
CLINIMIX E ..................... 32
CLINISOL ......................... 32
clobetasol propionate ........ 25
clonazepam ........................ 30
clonidine hcl ...................... 39
clotrimazole/betamethasone
dip .................................. 24
clozapine............................ 44
COLCRYS......................... 40
COMBIVENT ................... 48
COPAXONE ..................... 40
CREON.............................. 37
cyclobenzaprine hcl ........... 48
cyclophosphamide.............. 26
CYMBALTA ..................... 43
DALIRESP ........................ 47
dapsone .............................. 26
DENAVIR.......................... 24
DEPO-PROVERA ............. 43
desmopressin acetate ......... 42
desonide ............................. 25
dextroamphetamine sulfate 16
nacl................................. 32
dextrose 10%-0.5 normal
saline .............................. 32
dextrose 10%-water ........... 32
dextrose 2.5%-0.5normal
saline .............................. 32
dextrose 5 % and 0.33 % nacl
........................................ 32
dextrose 5 % and 0.9 % nacl
........................................ 32
dextrose 5 %-0.225 % nacl 32
dextrose 5 %-0.45 % nacl .. 32
dextrose 5 %-water ............ 33
dextrose 5%-lactated ringers
........................................ 46
diazepam ............................ 30
diclofenac sodium .............. 13
dicloxacillin sodium ........... 18
dicyclomine hcl .................. 19
digoxin................................ 34
DIGOXIN .......................... 34
DILANTIN ........................ 20
diltiazem hcl ....................... 31
DIOVAN............................ 45
DIOVAN HCT................... 45
diphenoxylate hcl/atropine. 22
divalproex sodium.............. 19
donepezil hcl ...................... 42
dorzolamide hcl/timolol
maleat............................. 23
doxazosin mesylate............. 12
doxycycline hyclate ............ 19
dronabinol.......................... 22
DROXIA ............................ 26
EFFIENT............................38
ELAPRASE........................36
ELIDEL..............................48
ELIGARD ..........................26
ELITEK..............................36
ELMIRON..........................41
EMEND..............................22
enalapril maleate................45
ENBREL ............................41
enoxaparin sodium .......37, 38
EPOGEN ............................39
EPZICOM ..........................29
ERAXIS WATER DILUENT
........................................23
erythromycin base ..............23
ESTRACE ..........................36
estradiol..............................36
ESTRING ...........................36
ethosuximide.......................20
EURAX ..............................24
EVISTA..............................36
EXELON............................42
exemestane .........................26
EXJADE.............................37
FABRAZYME ...................36
famciclovir..........................29
FAZACLO .........................44
FERRIPROX......................37
finasteride...........................41
flecainide acetate................33
FLOVENT DISKUS ..........12
FLOVENT HFA.................12
fluconazole .........................22
fluocinonide........................25
FLUOROPLEX..................48
fluorouracil.........................48
fluoxetine hcl ......................43
flutamide.............................26
fluticasone propionate........24
FORTEO ............................42
FORTICAL ........................42
FREAMINE III ..................33
FREAMINE III with
ELECTROLYTES .........33
I-2
furosemide ......................... 35
gabapentin ......................... 19
galantamine hbr................. 42
GAMMAGARD LIQUID . 47
GAMMAPLEX ................. 47
GAMUNEX-C................... 47
GELNIQUE ....................... 37
gemfibrozil ......................... 25
GENOTROPIN.................. 42
gentamicin sulfate.............. 18
GLEEVEC ......................... 26
glimepiride......................... 21
glipizide ............................. 21
GLUCAGEN ..................... 41
GLUCAGON EMERGENCY
KIT................................. 41
haloperidol......................... 45
HAVRIX............................ 49
HEPATAMINE ................. 33
HEPATASOL.................... 33
HIZENTRA ....................... 47
HUMALOG....................... 21
HUMATROPE .................. 42
HUMIRA ........................... 41
hydralazine hcl .................. 39
hydrochlorothiazide........... 35
hydrocodone bit/
acetaminophen......... 13, 14
hydrocortisone ................... 25
hydroxychloroquine sulfate 28
hydroxyurea ....................... 26
hydroxyzine hcl .................. 30
ibuprofen............................ 13
imipenem/cilastatin sodium 18
imiquimod .......................... 48
INCIVEK........................... 29
INCRELEX ....................... 48
INNOPRAN XL ................ 30
INTRALIPID..................... 33
INVANZ............................ 18
IONOSOL B with
DEXTROSE 5% ............ 46
IONOSOL MB-DEXTROSE
5%.................................. 46
ipratropium bromide.......... 35
ISENTRESS....................... 29
ISOLYTE H W/DEXTROSE
........................................ 46
ISOLYTE M W/DEXTROSE
........................................ 46
ISOLYTE P with
DEXTROSE................... 46
ISOLYTE S........................ 46
ISOLYTE S with
DEXTROSE................... 46
isoniazid ............................. 26
isosorbide mononitrate ...... 49
ISTALOL........................... 23
JAKAFI.............................. 26
JANUMET......................... 20
JANUMET XR .................. 20
JANUVIA .......................... 20
KADIAN............................ 14
KENALOG ........................ 25
ketoconazole................. 22, 24
ketorolac tromethamine ..... 24
LACTATED RINGERS .... 46
lactulose ............................. 13
LAMICTAL BLUE ........... 19
LAMICTAL ODT.............. 19
LAMICTAL ORANGE ..... 19
LAMICTAL XR ................ 19
LAMICTAL XR BLUE..... 19
LAMICTAL XR GREEN .. 19
LAMICTAL XR ORANGE
........................................ 19
lamotrigine......................... 19
LANTUS............................ 21
LANTUS SOLOSTAR ...... 21
latanoprost ......................... 23
leflunomide......................... 41
letrozole.............................. 26
LEUKERAN ...................... 26
leuprolide acetate............... 27
levetiracetam...................... 20
levocetirizine dihydrochloride
........................................ 23
levofloxacin ........................ 19
levonorgestrel-eth estradiol35
levothyroxine sodium..........49
LIALDA .............................24
lidocaine .............................28
lidocaine hcl .......................40
lidocaine/prilocaine ...........28
LIDODERM.......................28
LIPOSYN III ......................33
lisinopril .............................45
lisinopril/hydrochlorothiazide
........................................45
lithium carbonate ...............34
loperamide hcl....................22
losartan potassium .............45
losartan/hydrochlorothiazide
........................................45
LOVAZA ...........................25
LOVENOX.........................38
LUMIGAN .........................23
LUMIZYME ......................36
LUPRON DEPOT ..............27
LUPRON DEPOT-PED .....27
LYRICA .............................20
meclizine hcl.......................22
medroxyprogesterone acetate
........................................43
MEGACE ES .....................27
megestrol acetate................27
meloxicam...........................13
MENACTRA .....................49
MENVEO A-C-Y-W-135DIP .................................49
MEPRON ...........................28
mercaptopurine ..................27
meropenem .........................18
METADATE CD ...............16
metformin hcl......................20
methimazole........................49
methotrexate sodium ..........27
METHYLIN .......................16
methylphenidate hcl......16, 17
methylprednisolone ............12
metoclopramide hcl ............37
metoprolol succinate ..........30
I-3
metoprolol tartrate ...... 30, 31
metronidazole .............. 24, 28
MIACALCIN..................... 42
minocycline hcl .................. 19
mirtazapine ........................ 43
morphine sulfate ................ 14
MOXEZA .......................... 23
MULTAQ .......................... 34
mupirocin........................... 24
mycophenolate mofetil....... 41
MYOZYME....................... 36
nabumetone........................ 13
NAGLAZYME.................. 36
naloxone hcl....................... 41
naltrexone hcl .................... 41
NAMENDA....................... 34
naphazoline hcl.................. 35
naproxen ............................ 13
NASONEX ........................ 24
needles, insulin disposable 35
neo/polymyx b sulf/dexameth
....................................... 23
neomycin sulfate ................ 18
neomycin/polymyxin b sulf/hc
....................................... 23
NEPHRAMINE ................. 33
NEXAVAR........................ 27
nifedipine ........................... 31
NILANDRON ................... 27
NITRO-BID....................... 50
nitrofurantoin macrocrystal
....................................... 49
nitroglycerin ...................... 50
NITROSTAT ..................... 50
NORDITROPIN FLEXPRO
....................................... 43
NORDITROPIN
NORDIFLEX................. 43
noreth a-et estra/fe fumarate
....................................... 35
norethindrone acetate........ 43
norethindrone-ethinyl estrad
....................................... 35
norgestimate-ethinyl estradiol
........................................ 35
NORMOSOL-M and
DEXTROSE................... 46
NORMOSOL-R PH 7.4 ..... 46
NORVIR ............................ 29
NOVOLOG........................ 21
NUTROPIN ....................... 43
NUTROPIN AQ................. 43
NUTROPIN AQ NUSPIN . 43
NUVIGIL........................... 17
nystatin......................... 22, 24
ofloxacin............................. 23
olanzapine .......................... 45
omeprazole......................... 28
OMNITROPE .................... 43
ondansetron........................ 22
ondansetron hcl.................. 22
oxybutynin chloride............ 37
oxycodone hcl..................... 14
oxycodone hcl/acetaminophen
.................................. 14, 15
OXYCONTIN.................... 15
PANCREAZE .................... 37
pantoprazole sodium.......... 28
paroxetine hcl............... 43, 44
PATADAY ........................ 17
PATANASE....................... 17
PATANOL......................... 17
PAXIL................................ 44
PEGASYS.......................... 29
PEGASYS PROCLICK ..... 29
PEGINTRON..................... 29
PEGINTRON REDIPEN ... 29
penicillin v potassium ........ 18
PENTASA.......................... 24
pentoxifylline...................... 38
permethrin.......................... 24
perphenazine ...................... 45
PHENYTEK ...................... 20
phenytoin............................ 20
phenytoin sodium extended 20
PHOSLYRA ...................... 39
PLASMA-LYTE 148......... 46
PLASMA-LYTE 56 IN
DEXTROSE ...................46
PLASMA-LYTE A PH 7.4 46
pnv with ca,no.72/iron/fa ...50
polyethylene glycol 3350....34
potassium chlorid/d50.225nacl ........................46
potassium chloride .............46
potassium chloride in
0.9%nacl.........................46
potassium chloride/d50.33nacl ..........................46
potassium chloride/d50.45nacl ..........................46
potassium chloride/d50.9%nacl.........................47
potassium chloride/d5lr......47
potassium chloride/d5w......47
potassium chloride-0.45%
nacl .................................47
PRADAXA.........................38
pramipexole di-hcl..............28
PRANDIN ..........................21
prednisolone acetate ..........24
prednisone ..........................12
PREDNISONE INTENSOL
........................................12
PREMARIN .......................36
PREMASOL.......................33
PREMPHASE ....................36
PREMPRO .........................36
PREZISTA .........................29
primidone ...........................34
PRIVIGEN .........................47
PROAIR HFA ....................49
probenecid..........................41
PROCALAMINE ...............33
prochlorperazine maleate ..22
PROCRIT ...........................39
promethazine hcl ................23
proparacaine hcl ................40
propranolol hcl...................31
PROSOL.............................33
PROTONIX IV ..................28
I-4
PROTOPIC........................ 48
PULMOZYME.................. 36
quetiapine fumarate........... 45
QVAR................................ 12
ramipril.............................. 45
RANEXA........................... 34
ranitidine hcl...................... 29
REBIF................................ 41
RELENZA ......................... 29
RENVELA......................... 39
RESTASIS......................... 24
RETIN-A MICRO ............. 34
REVLIMID........................ 41
REYATAZ......................... 29
rifampin ............................. 26
ringers solution.................. 47
risperidone......................... 45
RITALIN LA..................... 17
ropinirole hcl ..................... 28
SAIZEN ............................. 43
SANTYL ........................... 48
SAVELLA ......................... 34
SENSIPAR ........................ 41
SEREVENT DISKUS ....... 49
SEROQUEL XR................ 45
SEROSTIM ....................... 43
sertraline hcl...................... 44
silver sulfadiazine .............. 24
simvastatin ......................... 25
SINGULAIR...................... 25
sodium chloride ................. 47
sodium chloride 0.45 % ..... 47
sodium chloride 3% ........... 47
sodium chloride 5% ........... 47
sodium chloride irrig solution
....................................... 40
sodium chloride/nahco3/kcl/
peg ................................. 34
SOLARAZE ...................... 13
SOMAVERT ..................... 48
SPIRIVA............................ 19
spironolact/
hydrochlorothiazid ........ 45
spironolactone ................... 46
SPRYCEL .......................... 27
STIMATE .......................... 43
STROMECTOL................. 17
SUBOXONE...................... 15
sulfamethoxazole/
trimethoprim .................. 19
sulfasalazine....................... 19
sumatriptan succinate ........ 25
SUTENT ............................ 27
SYLATRON ...................... 29
SYMBICORT .................... 12
syring w-ndl,disp,insul,0.5ml
........................................ 35
TAMIFLU.......................... 29
tamoxifen citrate ................ 27
tamsulosin hcl .................... 48
TARCEVA......................... 27
TARGRETIN..................... 27
TASIGNA .......................... 27
terazosin hcl ....................... 12
terbinafine hcl .................... 22
TESTIM ............................. 16
testosterone cypionate........ 16
TETANUS DIPHTHERIA
TOXOIDS ...................... 49
TEV-TROPIN .................... 43
theophylline anhydrous...... 47
timolol maleate................... 23
TOBRADEX ......................23
tobramycin sulf/
dexamethasone ...............23
torsemide ............................35
TPN ELECTROLYTES.....47
tramadol hcl .......................15
TRAVASOL.......................33
trazodone hcl ......................44
tretinoin ..............................34
TREXALL..........................27
triamcinolone acetonide.....25
triamterene/
hydrochlorothiazid .........35
TRICOR .............................25
trimethoprim.......................49
TROPHAMINE..................33
TRUVADA ........................29
TWINRIX...........................49
TYKERB............................27
TYPHIM VI .......................49
ULORIC .............................41
VAGIFEM..........................37
valacyclovir hcl ..................30
vancomycin hcl...................18
VAQTA..............................49
venlafaxine hcl....................44
VENLAFAXINE HCL ER.44
VENTOLIN HFA...............49
I-5
verapamil hcl ..................... 31
VESICARE........................ 37
VICTRELIS....................... 29
VIGAMOX........................ 23
VIREAD ............................ 29
VIVELLE-DOT................. 37
VOLTAREN...................... 13
VOTRIENT ....................... 28
VPRIV ............................... 36
warfarin sodium................. 38
water for irrigation,sterile. 40
WELCHOL........................ 25
XIFAXAN ......................... 18
zafirlukast .......................... 25
ZENPEP............................. 37
ZETIA................................ 25
zolpidem tartrate ............... 30
ZOMIG .............................. 26
ZOMIG ZMT..................... 26
ZORBTIVE ....................... 43
ZOSTAVAX...................... 49
ZOVIRAX ......................... 24
ZYCLARA ........................ 48
ZYMAXID ........................ 23
ZYPREXA......................... 45
ZYTIGA ............................ 28
FirstMedicare Direct HMO Plus and PPO Plus
2013 Provider Directory
This directory provides a list of FirstMedicare Direct’s network providers.
This directory is for the following counties: Hoke, Lee, Montgomery, Moore, Richmond and Scotland.
This directory is current as of October 1, 2012. Some network providers may have been added or removed
from our network after this directory was printed. We do not guarantee that each provider is still accepting new
members. To get the most up-to-date information about FirstMedicare Direct’s network providers in your area,
you can visit www.firstmedicare.com or call our Member Services Department at (888) 350-7794, from
October 1 - February 14, 8 a.m. to 8 p.m. (EST), seven days a week, and from February 15 -September 30, 8
a.m. to 8 p.m., Monday through Friday. TTY/TDD users should call 711.
FirstCarolinaCare Insurance Company is a health plan with a Medicare contract.
This document may be available in alternate formats or other languages. For more information, please call our
Member Services Department at (888) 350-7794, from October 1 - February 14, 8 a.m. to 8 p.m. (EST), seven
days a week, and from February 15 -September 30, 8 a.m. to 8 p.m., Monday through Friday. TTY/TDD users
should call 711.
H8064_13_17 Accepted 09302012
1|2013 Provider Directory
Introduction
This directory provides a list of FirstMedicare Direct’s network providers. To get detailed information about
your health care coverage, please see your Evidence of Coverage.
You will have to choose one of our network providers who are listed in this directory to be your Primary
Care Provider (PCP). The term “PCP” will be used throughout this directory. Generally, you must get your
health care coverage from your PCP. A PCP is a network provider you choose to provide your routine or
basic medical care. You may choose your PCP from among the following PCP-designated providers: a
physician specializing in Family Practice, General Practice, Internal Medicine, Geriatrics, Pediatrics, or
other physician specialist listed in the PCP section of the Provider Directory; a nurse practitioner (where
available); or a physician assistant (where available). In most cases, you should see your primary care
provider first for most health problems. He or she will make sure you get the care you need to keep you
healthy. He or she also may talk with other doctors and health care providers about your care and refer you
to them. A referral from your PCP is not required by the plan for you to see another network specialist.
The “network providers” listed in this directory have agreed to provide you with your health care and/or vision
coverage. You may go to any of our network providers listed in this directory. If you have been going to one
network provider, you are not required to continue going to that same provider. In some cases, you may get
covered services from non-network providers. Other physicians/providers are available in our network.
Generally, you see your PCP first for most of your routine health care needs. Your PCP can also help you
arrange or coordinate your covered services. This includes x-rays, laboratory tests, therapies, specialists,
hospital admissions, and follow-up care. Your PCP also contacts other plan providers for updates about your
care and/or treatment. In some cases, your PCP or provider will need to get prior authorization (prior approval).
Since your PCP will provide and coordinate your health care, you should have all of your past medical records
sent to your new PCP’s office. The law requires us to protect your privacy of medical records and personal
health information. For more information about privacy, see your Evidence of Coverage.
If you have a FirstMedicare Direct HMO Plus plan, you must use network providers except in emergency or
urgent care situations or for out-of-area renal dialysis or other services. If you obtain routine care from outof-network providers neither Medicare nor FirstMedicare Direct HMO Plus will be responsible for the
costs. FirstMedicare Direct PPO Plus members may pay more to get care from out-of-network providers,
except in the case of emergencies or urgent care.
If you are a member of our PPO Plus Plan, you do not need prior authorization to use non-network (out-ofnetwork) providers. If an out-of-network provider sends you a bill, submit the bill to us for processing. With
the exception of emergencies or urgent care, it may cost you more to get care from out- of-network providers.
If you have a medical emergency: Get help as quickly as possible. Call 911 for help or go to the nearest
emergency room, hospital, or urgent care center. Call for an ambulance if you need it. You do not need to
get approval or a referral first from your PCP. As soon as possible, make sure that our plan has been told
about your emergency. You or someone else should call to tell us about your emergency care, usually within
48 hours. The number to call is located on the back of your membership identification card.
What is the service area for FirstMedicare Direct?
The counties in our service area are listed below:






Hoke
Lee
Montgomery
Moore
Richmond
Scotland
How do you find FirstMedicare Direct providers in your area?
Primary Care Providers (PCPs) are listed in Section 1. To locate a PCP, find the desired county and search the
list. Providers are listed alphabetically within each category by practice or company name.
All participating providers except Primary Care Providers (PCPs) are listed in Section 2, Specialists, Ancillary
Services and Hospitals. To locate a specialist, ancillary service, or hospital, find the desired county and search
the list of provider categories, listed alphabetically. Providers are listed alphabetically within each category by
practice or company name.
If you have questions about FirstMedicare Direct or require assistance in selecting a PCP, please call our
Member Services Department at (888) 350-7794, from October 1 - February 14, 8 a.m. to 8 p.m. (EST), seven
days a week, and from February 15 -September 30, 8 a.m. to 8 p.m., Monday through Friday. TTY/TDD users
should call 711. Or visit our website at www.firstmedicare.com
Section 2 – List of Network Providers
The Provider Directory is organized as follows:
Type of Provider (PCP, Behavioral Health, Specialists, Hospitals and other services; such as Home Health and
Skilled Nursing)
County (Listed alphabetically in each section)
Specialty or Sub-Specialty (such as Family Practice, Internal Medicine, or
Cardiologist listed alphabetically in each section)
City (Listed alphabetically)
Provider or Practice Name (Listed alphabetically in each section)
Address and phone number
Network Provider Listing
Primary Care / Atencion Primaria
Chatham County
Internal Medicine
Family Medicine
Pittsboro Family Medicine
855 East St
Ste 9
Pittsboro, NC 27312
(919)545-0911
Chatham Primary Care
163 Medical Park Dr
Ste 210
Siler City, NC 27344
(919)742-6032
Deborah M Esteves, MD
Gary N Asher, MD
Cumberland County
Michael Buebel, MD
Family Medicine
Laura A Hester, MD
Kia Williams, MD
Anderson Creek Medical Center
6750 Overhills Rd
Spring Lake, NC 28390
(910)436-2900
East Chatham Medical Center
75 Old Graham Rd
Pittsboro, NC 27312
(919)542-2731
Enobong Amao, MD
Erik S Butler, DO
Jiho Choi, MD
Dawn A Erikson, FNP
Amritpal K Manes, MD
Sujatha Sajeevan, MD
Jaimita V Patel, MD
Durham County
Internal Medicine
Family Medicine
Chatham Medical Specialists, PA
421 N Holly Ave
PO Box 689
(919)663-3360
Highgate Family Medical Center
5317 Highgate Dr
Ste 117
Durham, NC 27713
(919)361-2644
Bruce T Granger, MD
Bryon J Hoffman, MD
Libre E Johnson, MD
UNC Physicians Network, LLC
421 N Holly Ave
SILER CITY, NC 27344
Bryon J Hoffman, MD
* Spanish spoken/interpreter available
cl Closed to new Primary Care Patients
A- 1
October 2012
Henderson County
Pediatrics
Family Medicine
University Pediatrics at Highgate
5322 Highgate Dr
Ste 144
Durham, NC 27713
(919)361-2644
Urgent Cares of America NC at Hendersonville
825 Spartanburg Hwy
Ste 17
Hendersonville, NC 28792
(828)233-1664
Sheryl Starnes, MD
Dana L Garrett, MD
Harnett County
Hoke County
Family Medicine
Family Medicine
Boone Trail Medical Center
1000 Medical Center Rd
Mamers, NC 27552
(910)893-5402
Raeford Family Care Center, PC
1090 E Central Ave
Raeford, NC 28376
(910)875-4545
Enobong Amao, MD
Vickie L Farmer, PA-C
Deborah L Morris, MD
Angier Medical Center
84 Medical Dr
Angier, NC 27501
(919)639-2122
Chuck T Nguyen, MD
FirstHealth Family Care Center - Jordan Clinic
116 Campus Ave
Raeford, NC 28376
(910)875-9087
Enobong Amao, MD
Jiho Choi, MD
Jorge L Caceres, PA-C
Jaimita V Patel, MD
FirstHealth Family Care Center- Raeford
313 Teal Dr
Raeford, NC 28376
(910)904-2350
Benhaven Medical Center
985 NC 87 S
Cameron, NC 28326
(919)499-9422
Jeffrey J Kern, PAC
Enobong Amao, MD
Garnett M Lowry, MD
Jaimita V Patel, MD
Christopher T McLaren, PA-C
Valerie D Taylor, PA-C
Robert G Townsend, III, DO
A- 2
October 2012
Lee County
Family Medicine
Family Medicine
FirstHealth FirstCare Convenient Care Center
4565 Fayetteville Rd
RAEFORD, NC 28376
(910)878-5100
Sandhills Family Practice
101 Church St
Broadway, NC 27505
(919)258-6521
Jeffrey J Kern, PAC
Jessica W Burgert, MD
Marshall S Nickel, MD
Stephen H Cox, MD
Thomas L Wilkins, PA
Jill J Lambert, MD
Parker S McConville, MD
Karen L Smith, MD, PA
929 W Prospect Ave
Raeford, NC 28376
(910)904-1695
Robert H McConville, MD
June L Peck, FNP
Beth P Stanfield, FNP
Daniel P Woydick, MD
Karen L Smith, MD
Sandhills Family Practice
1125 Carthage St
Sanford, NC 27330
(919)774-6023
IREDELL County
Family Medicine
Urgent Cares of America NC Inc.
107A Commons Dr
MOORESVILLE, NC 28117-9262
(704)235-0686
Stephen H Cox, MD
Jill J Lambert, MD
June L Peck, FNP
234 Turnersburg Hwy
STATESVILLE, NC 28625-2797
(704)818-0369
24 0n Physicians, PC
1135 Carthage St
Sanford, NC 27330
(919)708-4627
A- 3
October 2012
Family Medicine
Internal Medicine
Brick City Primary Care, PLLC
125 Chatham St.
PO Box 237
Sanford, NC 27331-0237
Doctors Vital Care and Screening, LLC
111 Dennis Dr
Ste 123
Sanford, NC 27330
(919)776-7725
Dana L Garrett, MD
Ajay K Ajmani, MD
1911 K M Wicker Memorial Dr
SANFORD, NC 27330
(919)775-1000
Internal Medicine Associates, PA
1139 Carthage St
Ste 110
Sanford, NC 27330
(919)774-2195
William E Hall, MD
Chassidy S Young, PA
Charles A Eure, MD
William E Hall MD, PA
1911 KM Wicker Dr
Sanford, NC 27330
(919)775-1000
Gerard J O'Donnell, MD
Sanford Specialty Clinic
1301 Central Dr
Sanford, NC 27330
(919)718-9512
William E Hall, MD
Community Family Medicine and Obstetrics
2412 Wilkins Dr
Sanford, NC 27330
(919)776-6000
Pinehurst Medical Clinic, Inc
555 Carthage St
Sanford, NC 27330
(919)774-6518
Erik S Butler, DO
Dawn A Erikson, FNP
Glenna L Grider, MD
Jennifer B Normann, MD
555 Carthage St
Sanford, NC 27330
(919)774-6518
Brian C Torgerson, MD
Mid Carolina Primary Care, PA
709 C Wicker St
Sanford, NC 27330
(919)777-2704
Glenna L Grider, MD
John R Mangum, MD
Vaishali R Nadkarni, MD
Kim A Finlay-Tozzi, DO
Lester D Nave, MD
Joseph A Tozzi, MD
Murali D Pisharody, MD
A- 4
October 2012
Pediatrics
Family Medicine
555 Carthage St
Sanford, NC 27330
(919)774-6518
FirstHealth Family Care Center - Troy
522 Allen St
Ste 101
Troy, NC 27371-2861
(910)571-5510
Chrystal F Eller, MD
Marlboro County
Kimberley Sierra Lingler, MD
Robert L Thomas, PA-C
Family Medicine
Moore County
Scotland Healthcare Center
668 Hwy 15-401 Bypass E
Bennettsville, SC 29512
(843)454-0245
Family Medicine
Pinehurst Family Care Center, PA
10 Aviemore Dr
Pinehurst, NC 28374
(910)215-5555
David A Howell, MD
Jonathan Rowson, MD
*
Montgomery County
Alice D Beane, FNP
Susan G Brassil, PA
Family Medicine
John W Jameson, III, MD
Mid Carolina Family Medicine, PA
1038 Albemarle Rd
PO Box 726
Troy, NC 27371-0726
(910)572-1785
Douglas E Lam, MD
Janet Ann Leone-Britt, PAC
FirstHealth Family Care Center - Seven Lakes
1035 C Seven Lakes Dr
PO Box 789
West End, NC 27376
(910)673-0045
Matthew T Manzo, DO
Emily G Parker, PA
Touber Vang, MD
Family Care Associates
507 N Main St
Troy, NC 27371
(910)576-0042
Bohdan W Kopynec, MD
Daniel A Matthews, PAC
Carolyn E Green, PA-C
John M Woodyear, Jr, MD
*
A- 5
October 2012
Family Medicine
Family Medicine
Family Care Associates
113 MacDougall Dr
West End, NC 27376
(910)673-2422
Moore Family Care, PA
3349 US Hwy 1
PO Box 647
Vass, NC 28394
(910)245-7678
Marcia H Ballard, FNP
*
Thomas R Leonard, MD
Pinehurst Medical Clinic South
1902-C N Sandhills Blvd
Aberdeen, NC 28315
(910)692-4011
Todd R Nicholson, PAC
Vonda H Reives, FNP
Geriatric Medicine
John R Mangum, MD
205 Page Rd
Pinehurst, NC 28374
(910)295-5511
301 S Middleton St
Robbins, NC 27325
(910)948-2059
Sangeeta C Varanasi, MD
Vonda H Reives, FNP
*
Internal Medicine
*
304 Saunders St
Carthage, NC 28327
(910)947-3000
Neese Clinic of Pinehurst Medical Clinic, Inc
102 Gossman Dr
Southern Pines, NC 28387
(910)246-4140
Robert L Deucher, MD
Michol Stanzione, DO
Vonda H Reives, FNP
*
A- 6
October 2012
Internal Medicine
Internal Medicine
15 Regional Dr
Pinehurst, NC 28374-8850
(910)255-4400
FH Hospice and Palliative Care
251 Campground Rd
WEST END, NC 27376
(910)715-6100
Michael A Antil, MD
*
Daniel R Barnes, DO
Julie G Baugher, MD
Stephen K Chiu, MD
Jeffrey N Binney, MD
Aaron M Gavett, DO
Greg M Blakely, MD
Kelly Ennix King, MD
Jackson V Gibson, MD
Artur G Mixa, MD
David E Hipp, MD
Dorothy B Mixa, MD
Kathleen A Letizia, MD
Saul A Salvador, MD
Philip G Mondi, MD
Ovidiu Gabriel Silasi, MD
Fabian D Rodriguez, MD
Van Slaughter, Jr, MD
Michael F Soboeiro, MD
Ronald D Walters, MD
293 Olmsted Blvd
Ste 1
Pinehurst, NC 28374
(910)255-0033
Jennifer G Szurgot, MD
Padiwath C Ung, MD
Pinehurst Medical Clinic South
1902-C N Sandhills Blvd
Aberdeen, NC 28315
(910)692-4011
Pulmonary Diseases
Thomas H Lineberger, MD
Cheryl R Rachels, FNP
205 Page Rd
Pinehurst, NC 28374
(910)295-5511
205 Page Rd
Pinehurst, NC 28374
(910)295-5511
Francis Farrell Collins, Jr, MD
Bobby R Maynor, Jr, MD
Walter S Morris, III, MD
A- 7
October 2012
Orange County
Family Medicine
Family Medicine
UNC Urgent Care at Carolina Pointe III
6013 Farrington Rd
Ste 101
CHAPEL HILL, NC 27517-8172
(919)957-6610
UNC Hospitals & Clinics
101 Manning Dr
PO Box 168
Chapel Hill, NC 27514
(919)966-4131
Matthew T Sproul, MD
Gary N Asher, MD
Internal Medicine
James G Blount, MD
Wanda J Boggs, FNP
101 Manning Dr
PO Box 168
(919)966-4131
Michael Buebel, MD
Sandeep S Gavankar, DO
Laura A Hester, MD
Libre E Johnson, MD
Emily Y Joubert, CNM
Susan M Berendzen, MD
Nancy J Plemmons, FNP
Amy Bouthilette, LDN
Mark D Raupp, MD
Arlene E Chung, MD
Philip D Sloane, MD
David H Curl, PA
Denise H Sutherland-Phillips, MD
Darren Dewalt, MD
Kia Williams, MD
Cynthia K Feltner, MD
UNC Family Medicine at Hillsborough
2201 Old NC 86
Hillsborough, NC 27278
(919)732-2909
Catherine Fine, CGC
Bruce T Granger, MD
Hans H Herfarth, MD
Kristy Lee, CGC
Kia Williams, MD
Philip M Mendys, PharmD
Lori A Meyerhoffer, MD
Family Medicine Center
590 Manning Dr
Carlton R Moore, MD
Carrie Palmer, NP
Leslie C Powell, CRNP
Jack M McBride, MD
Elizabeth M Prata, FNP
Sarah C Ruff, MD
Jessica J Stewart, MD
A- 8
October 2012
Internal Medicine
Pediatrics
Chatham Crossing Medical Center
11312 US Hwy 15-501 North
Ste 308
Chatham Crossing Medical Center
11312 US Hwy 15-501 North
Ste 308
Sheryl Starnes, MD
University Internal Medicine at Chapel Hill
North
1838 Martin Luther King Dr
Ste B-19
(919)960-5154
University Pediatrics at Chapel Hill North
Ste B-19
(919)960-5154
Carrie Palmer, NP
Sheryl Starnes, MD
Pediatrics
Chapel Hill Children's Clinic
301 Kildaire Rd
Ste 200
(919)967-0771
101 Manning Dr
PO Box 168
(919)966-4131
William L Coleman, MD
Michael Minozzi, MD
Karen J Behling, MD
Molly C Berkoff, MD
Richmond County
Deanna K Branscom, MD
Family Medicine
Wallace Brown, MD
FirstHealth Family Care - Carolina Family
Medicine
104 Physicians Park Dr
Rockingham, NC 28379
(910)895-1989
Ian J Davis, MD
Michael Minozzi, MD
Sara A Reason, PNP
Carl J Seashore, MD
Sheryl Starnes, MD
Daniel C Hall, MD
Jeffrey J Kern, PAC
Lynn M Wegner, MD
A- 9
October 2012
Family Medicine
Internal Medicine
FirstHealth Family Care Center-Ellerbe
112 E Ballard St
Ellerbe, NC 28338
(910)652-2663
Richmond Internal Medicine
115 Mallard Lane
(910)997-3313
Johnny E Camargo, MD
Julie M Thomas, PA-C
Shilpesh P Patel, MD
Tarheel Family Medicine PA
224 W Main St
Ste A
Hamlet, NC 28345
(910)582-2696
Rockingham Medical Clinic PC
115 Medical Circle
Rockingham, NC 28379-5221
(910)817-9266
*
*
Melva R Bowman, MD
Sandhills Internal Medicine Clinic, PA
125 Biltmore Drive
Ste 2
(910)895-6650
FH Richmond Med Group Internal Med
809 S Long Dr
Ste H
(910)417-4005
Amir M Darwish, MD
Mohammed Sharouk Khader, MD
First Choice Medical Group
921 E Broad Ave
(910)895-6042
FH Richmond Med Group Internal Med
809 S Long Dr
Ste H
(910)417-4005
Wendell D Wells, MD
Stephen K Chiu, MD
Joseph G Gibbons, DO
FirstHealth Family Care - Richmond
921 Long Dr
Ste 101
(910)417-3850
Anthony Tonos, MD
Amanda H Martin, ANP
Steven D Millen, ANP
A - 10
October 2012
Robeson County
Family Medicine
Family Medicine
Bradford K Faulkenberry, MD, PA
1707-A Berwick Dr
Laurinburg, NC 28352
(910)276-2439
Maxton Family Practice Center
1001 W Dr Martin Luther King Jr Dr
Maxton, NC 28364
(910)844-4077
Bradford K Faulkenberry, MD
Chamaine R Brooks, MD
Wagram Family Practice
24420 Marlboro St
Wagram, NC 28396
(910)369-3136
Ashleigh J Freeman, MD
Camille M Gardner, MD
Shelly S Lowery, MD
Rowland Family Practice Center
2362 Hwy 130 W
Rowland, NC 28383
(910)422-8811
Taneka M Williams, MD
Scotland Urgent Care
500 Lauchwood Dr
(910)277-8300
Pembroke Family Practice
410 D Jones St
Pembroke, NC 28372
(910)521-4462
Jonathan Rowson, MD
*
Internal Medicine
Harris Family Practice
700 A Progress Place
(910)276-6767
Shelly S Lowery, MD
Richard C Wolonick, DO
Ashley K Lamb, MD
Scotland County
Family Medicine
Habiba Tunau, MD, PLLC
705A Lauchwood Dr Prestwick Pk
Laurinburg, 28352
(910)266-0062
Wolonick Family Practice
106 McAlpine Lane
(910)277-8044
Habiba Tunau, MD
A - 11
October 2012
UNION County
Family Medicine
Family Medicine
Cedar Creek Medical Group
1418 Main St
Fuquay-Varina, NC 27526
(919)552-1733
2242-A W Roosevelt Blvd
MONROE, NC 28110-3071
(704)220-1904
Dana L Garrett, MD
Boylan Healthcare
3900 Browning Place
Ste 101
RALEIGH, NC 27609-6529
(919)781-9650
Vance County
Family Medicine
Four County Primary Care
120 Charles Rollins Road
Ste 102
Henderson, NC 27536
(252)436-0440
Gregory C Appert, MD
Don L Zust, DO
Garner Family Practice
801 Poole Dr
GARNER, NC 27529
(919)779-1440
Kia Williams, MD
WAKE County
Family Medicine
Johnny W Bagwell, MD
Rex Family Practice of Wakefield
11200 Governor Manly Way
Ste 205
(919)570-7700
Thomas D Brammer, MD
Amy Walsh, MD
Gregory T Pleasants, MD
Kathryn J Bland, NP
Randall S Crumpler, MD
Suzanne E Eaton-Jones, MD
Erin K Ennis, MD
Jason D Jones, MD
Tina H Scott, FNP
114 Brady Court
CARY, NC 27511
(919)469-1252
David E Spivey, MD
Jodi M Winkel, MD
Elizabeth B Gibbons, MD
Gregory R Gibbons, MD
A - 12
October 2012
OB/GYN / Obstetricia/Ginecologo
Hoke County
Internal Medicine
Obstetrics & Gynecology
Boylan Healthcare
3900 Browning Place
Ste 101
(919)781-9650
Southern Pines Women's Health Center, PC
313 Teal Dr
Raeford, NC 28376
(910)692-4038
Todd E Helton, MD
8300 Health Park Dr
Ste 309
(919)781-9650
Barry K Buchele, MD
*
John W Byron, MD
*
Pamela G Kantorowski, MD
Kendall R Zmiewsky, MD
Lee County
Teresa Terezis, MD
Carolina Women's Health Center, PA
1140 Carthage St
Sanford, NC 27330
(919)775-2304
Pediatrics
NC Children's Specialty Clinic
4414 Lake Boone Trail
Ste 505
Raleigh, NC 27607
(919)783-7809
Margaret A Davis, CNM
Jennifer J Delaney, DO
Andrea T DiMichele-Manes, MD
Tiffany S Flanagan, MD
Lynn M Wegner, MD
Lisa L Jones, MD
Rita H Kelly, CNM
Chatham County
Advanced Care for Women
127 N Steele St
Sanford, NC 27330
(919)776-7640
75 Old Graham Rd
Pittsboro, NC 27312
(919)542-2731
Paul M Heimbecker, MD
Benjamin K Merritt, MD
Cynthia C Julich, FNP
Michael J Tyler, MD
A - 13
October 2012
MONTGOMERY County
Pinehurst Surgical, PA
1818 Doctors Dr
Sanford, NC 27330
(919)895-6340
FirstHealth Richmond Medical Group Women's
Center
522 Allen St
Ste 103
TROY, NC 27371
(910)571-5710
Stephen A Szabo, MD
William V Terry, MD
2412 Wilkins Dr
Sanford, NC 27330
(919)776-6000
Mohamed A Y Ibrahim, MD
Donald C Jones, MD
Angela S Morrison, MD
Rasheed A Yakubu, MD
Moore County
Michael J Tyler, MD
Marlboro County
Marlboro OB/GYN, PA
1007 Cheraw St
145 Applecross Rd
PO Box 749
(910)692-7928
John R Nobles, MD
Sarah D Bowen-Pasfield, MD
Barry K Buchele, MD
*
Carolina Women's Center
668 Hwy 15501 Bypass E
(843)479-8400
John W Byron, MD
*
Walter S Fasolak, DO
*
Anila R Ricks-Cord, MD
Paul W Whitecar, MD
A - 14
*
October 2012
5 FirstVillage Dr
PO Box 2000
Pinehurst, NC 28374
(910)295-0290
University OB/GYN at Chapel Hill North
Ste B-19
(919)960-7461
Daniel L Rowland, MD
Michael D Evers, MD
Stephen A Szabo, MD
Richmond County
William V Terry, MD
Susan Kady Wilson, MD
Pinehurst Women's Clinic
70 Memorial Dr
Pinehurst, NC 28374
(910)295-4342
110 Medical Circle Dr
(910)895-7528
Ellen T Puleo, MD
Orange County
Barry K Buchele, MD
*
John W Byron, MD
*
*
101 Manning Dr
PO Box 168
(919)966-4131
FirstHealth Richmond Medical Group Women's
Center
921 S Long Dr
Ste 207
(910)417-3477
Don M Armstrong, MD
Daniel Clarke-Pearson, MD
Stephanie M Devane-Johnson, CNM
Elisabeth A Dinkins, FNP
Nasser A Askary, MD
Michael D Evers, MD
John T Soper, MD
Donald C Jones, MD
Anne Z Steiner, MD
Laura Stutts Marks, NP
Gretchen S Stuart, MD
Alison M Stuebe, MD
A - 15
October 2012
Behavioral Health / Salud Mental
Robeson County
Cumberland County
Behavioral
1001 Martin Luther King Jr
Maxton, NC 28364
(910)844-2267
Cardinal Clinic, LLC
1540 Purdue Dr
Ste 200
Fayetteville, NC 28303
(910)693-7777
Linda K Mitchell-Frye, MD
Veda W Lydon, LCSW
Pembroke OB/GYN
410D S Jones St
Pembroke, NC 28372
(910)521-3947
Charmac Professional Counseling and
Consultation Services
213 St Thomas Rd
Charlene A McLaurin, LPC
Haymount Institute For Psychological Services
806 Hay St
Fayetteville, NC 28305-5312
(910)860-7008
Scotland County
105 McAlpine Lane
(910)277-3331
Cheryl A Boeckenstedt, LPA
Laura D Coyle, LPA
Samantha M Daniel, PhD
Frederick R Dryden, LPC
Margaret M Flatley, LPA
Elizabeth C Franco, MSW
Scotland Womens Care
705 B Lauchwood Dr
(910)276-7552
Patricia L Middleton, MD
Alfred Gray, LPC
Tracie S Hector, LPA
Diane C Jackson, LCSW
Christopher J Ketchman, PsyD
Stacey A Ketchman, PsyD
*
Shelia A Leese-Roberts, LCSW
Ronnie W Martin, LPC
Ramona M Miller, PsyD
Heggadadevanako N Nataraja, MD
Mizanur Rahman, MD
Jessica L Soule, LCSW
A - 16
October 2012
Hoke County
Moore County
Behavioral
Behavioral
131 W Edinborough Ave
Raeford, NC 28376
(910)848-1222
103 Bradford Village Ct
(910)692-2947
Laura D Coyle, LPA
Alfred Gray, LPC
Cardinal Clinic, LLC
160J Pinehurst Ave
(910)693-7777
Alfred Gray, LPC
Gail A Vincent, PhD
MaryAnn McCrary, LCSW
2212 Midland Rd
Pinehurst, NC 28374
(910)528-0991
Mizanur Rahman, MD
MaryAnn W McCrary, LCSW
Lee County
Behavioral
555 Carthage St
Sanford, NC 27330
(919)774-6518
Heather B Scheffler, PhD
A - 17
October 2012
Behavioral
Behavioral
Carolina Behavioral Care, PA
289 Olmsted Blvd
Ste 1
Pinehurst, NC 28374
(910)295-6007
Lynn L. Palin, LCSW
780 NW Broad St
Ste 300
(910)693-1000
Linda J Aycock, LPC
Lynn L Palin, LCSW
Carole M Crump, PAC
Psychiatry
Mary H Edge, LCSW
Linda M Evans, LCSW
Rodolfo de los Santos Ongjoco, Jr, MD, PA
180 Perry Dr
(910)246-0567
Gabriele D Jones, PhD
Mattie L Jones, PhD
Delight C Thompson, PsyD
Rodolfo S Ongjoco, Jr, MD
W Gregory Walton, PhD
Donna M Wiener, PhD
289 Olmsted Blvd
Ste 1
Pinehurst, NC 28374
(910)295-6007
FirstHealth Behavioral Health Services
35 Memorial Dr
Pinehurst, NC 28374
(910)715-3370
Robert A Fleury, MD
Nancy K Davis, MSW
Olin M Fox, MD
Elizabeth Harry, LCSW
Benjamin L Ose, MD
Elizabeth A Manley, MSN
David C Ruck, MD
Suzanne G Martin, PsyD
Charlie L Swanson, Jr, MD
Robert A Peterson, LPC
Ellen B Starnes, LCSW
FirstHealth Behavioral Health Services
35 Memorial Dr
Pinehurst, NC 28374
(910)715-3370
Elizabeth M Watson, PMH-NP
Gabriele Jones, PhD, PA
5 Regional Cercle
Ste C
Pinehurst, NC 28374
(910)255-1000
George D Bussey, MD
Mary T Mandell, MD
Benjamin L Ose, MD
David C Ruck, MD
A - 18
October 2012
Orange County
Richmond County
Behavioral
Behavioral
101 Manning Dr
PO Box 168
(919)966-4131
109 Medical Circle
Ste A
(910)895-0980
Nancy L Berson, LCSW
Carole M Crump, PAC
Lyse Bourguignon, LCSW
Mary H Edge, LCSW
Mary M Crowston, PhD
Karen J Cusack, PhD
Mattie L Jones, PhD
Lyse M De Bourguignon, LCSW
Kathryn R Flanagan, CCSW
Gary J Gala, MD
Jemma C Grindstaff, PhD
Donna M Wiener, PhD
Nadiya L Kaesemeyer, MD
Psychiatry
Alexei B Kampov, LCSW
Julia S Knerr, MD
109 Medical Circle
Ste A
(910)895-0980
Maria La Via, MD
Lauri K Langham, LCSW
Lynette A Mappes, LCSW
Brenda L Pearson, LCSW
Victoria M Petrilli, LDN
Robert A Fleury, MD
Thomas J Raney, PhD
Olin M Fox, MD
Shane W Rau, MD
David C Ruck, MD
Heather A Rogers, MD
David R Rubinow, MD
Rebecca S Siegel, PhD
Specialists / Especialista
Jair C Soares
Alamance County
Dermatology
UNC Dermatology at Burlington
1522 Vaughn Rd
Burlington, NC 27217
(919)966-2485
Dean Morrell, MD
A - 19
October 2012
Anson County
Geriatric Medicine
Urology
75 Old Graham Rd
Pittsboro, NC 27312
(919)542-2731
Richmond Urology Clinic, PA
500 Morven Rd
Wadesboro, NC 28170
(704)694-5131
James B Holt, MD
Hazem El-Droubi, MD
Urology
Buncombe County
Chatham Urology Clinic
401 N Ivey Ave
(910)663-3317
Allergy/Immunology
Allergy Partners, PA
1978 Hendersonville Rd
Ste 130
Asheville, NC 28803
(828)350-2163
Daljit S Caberwal, MD
*
Prithvi Hanspal, MD
*
Chesterfield County
Diane Krane Laber, MD
Opthalmology
Chatham County
Carolina Eye Associates, PA
705 Chesterfield
PO Box 1237
Cheraw, SC 29520
(843)537-7711
Dermatology
75 Old Graham Rd
Pittsboro, NC 27312
(919)542-2731
John W French, MD
Gregory J Mincey, MD
John D Cheesborough, MD
Optometry
Emergency Medicine
705 Chesterfield
PO Box 1237
Cheraw, SC 29520
(843)537-7711
Chatham Professional Group
475 Progress Blvd
(919)966-7890
William S Boyd, PAC
Katie C Hickman, OD
A - 20
October 2012
Cumberland County
Opthalmology
Allergy/Immunology
1991 Fordham Dr
Ste 301
(910)485-2020
Allergy Partners of Fayetteville
1317 Medical Dr
Carla J Luna, MD
John W French, MD
Neurosurgery
Neil B Griffin, MD
Carolina Neurosurgical Services
3650 Cape Center Dr
Ste 100
(910)484-9802
Daniel K Messner, MD
Robert K Shuler, Jr, MD
Jeffrey J White, MD
Optometry
Larry V Carson, MD
1991 Fordham Dr
Ste 301
(910)485-2020
Anneliese Jacobson, PAC
Bruce P Jaufmann, MD
Carol M Wadon, MD
Opthalmology
Carson C Cox, OD
Cape Fear Eye Associates, PA
1726 Metromedical Dr
(910)484-2284
Joey L Harris, OD
John D Miller, OD
David B Throneburg, OD
Durham County
Sheel B Patel, MD
Endocrinology
UNC Specialty Center
5316 Highgate Dr
Ste 125
Durham, NC 27713
(919)966-7890
Lauren K Samford, CPP
A - 21
October 2012
Pediatrics
Orthopedic Surgery
University Pediatrics at Highgate
5322 Highgate Dr
Ste 144
Durham, NC 27713
(919)361-2644
313 Teal Dr
Raeford, NC 28376
(910)295-6831
Ward S Oakley, Jr, MD
David C Kwee, MD
Pain Management
Sarah P Zimmerman, MD
FirstHealth Back and Neck Pain Center
Ste B
Raeford, NC 28376
(910)878-5150
Harnett County
Opthalmology
107 Hunt Dr
Dunn, NC 28334
(910)891-4129
David L Chandler, DO
Robert G Oldroyd, MD
Lawrence Burt Place, MD
Jeffrey J White, MD
Lee County
HOKE County
Cardiology
Emergency Medicine
FirstHealth FirstCare Convenient Care Center
RAEFORD, NC 28376
(910)878-5100
Sanford Cardiology
110 Fields Dr
Ste A
Sanford, NC 27330
(919)777-9005
Lisa R Cowan, MD
Mahmoud K Atieh, MD
David M Cowherd, MD
Keith E Davis, MD
General Surgery
Michael J Gillespie, MD
313 Teal Dr
Raeford, NC 28376
(910)295-6831
Lukas Jantac, MD
Steven M Kent, MD
Joseph L Parrish, MD
Patrick J Simpson, MD
Huey Willy Chu, MD
A - 22
October 2012
Cardiology
General Surgery
Sanford Specialty Clinic
1301 Central Dr
Sanford, NC 27330
(919)718-9512
Mid Carolina Surgical Clinic, PA
709 B Wicker St
Sanford, NC 27330
(919)775-3321
J Larry Klein, MD
Michael A Gordon, MD
Chiropractic
Geriatric Medicine
Knecht Chiropractic Center
2631 S Horner Blvd
Sanford, NC 27332
(919)777-5242
2412 Wilkins Dr
Sanford, NC 27330
(919)776-6000
Andre Knecht, DC
James B Holt, MD
Dermatology
Neurology
Sanford Dermatology, PA
827 S Horner Blvd
Sanford, NC 27330
(919)775-7926
Mohan C Deochand, MD
114 S Gulf St
(919)774-4536
Gastroenterology
Opthalmology
Mid Carolina Gastroenterology Associates PA
110 Dennis Dr
Sanford, NC 27330
(919)774-4511
1223 Carthage St
Sanford, NC 27330
(919)776-7549
Sebastian Abadie, MD
Anna F Fakadej, MD
Behnam Asgharian, MD
Tarra Wright Millender, MD
*
Robert D McCall, Jr, MD
Marion B Pate, III, MD
A - 23
October 2012
Optometry
Otolaryngology
1223 Carthage St
Sanford, NC 27330
(919)776-7549
1818 Doctors Dr
Sanford, NC 27330
(919)895-6340
Carson C Cox, OD
Carl W Berk, MD
Joey L Harris, OD
Central Carolina ENT Associates, PA
1915 KM Wicker Memorial
Sanford, NC 27330
(919)774-6829
Orthopedic Surgery
Central Carolina Orthopaedic Associates, PLLC
1139 Carthage St
Ste 101
Sanford, NC 27330
(919)774-1355
Samuel P Davis, III, MD
William C LeLiever, MD
Doris Lin, MD
Christine A Lupienski, RN, FNP
Andrew P Bush, MD
Kevin R Pilecki, PA
Pain Management
Theodore M Pitts, MD
FH Back and Neck Pain Center
1227 Carthage St
SANFORD, NC 27330-8984
1818 Doctors Dr
Sanford, NC 27330
(919)895-6340
Brian K Thwaites, MD
James V Winkley, MD
Neil A Conti, MD
Pulmonary Diseases
Central Carolina Orthopaedic Associates, PLLC
1911 Bragg St
PO Box 3247
(919)774-1355
Sanford Cardiology
110 Fields Dr
Ste A
Sanford, NC 27330
(919)777-9005
Andrew P Bush, MD
Sonal Arora, MD
A - 24
October 2012
Urology
Orthopedic Surgery
1818 Doctors Dr
Sanford, NC 27330
(919)895-6340
Specialty Care Clinic
522 Allen St
Ste 203
Troy, NC 27371
(910)571-5710
Greg L Griewe, MD
David J Casey, MD
Vascular Surgery
David P Fedder, MD
1818 Doctors Dr
Sanford, NC 27330
(919)895-6340
Otolaryngology
Robert J Albrecht, MD
522 Allen St
Ste 203
Troy, NC 27371
(910)571-5710
*
MARLBORO County
Carl W Berk, MD
Orthopedic Surgery
Jefferson K Kilpatrick, MD
OrthoCarolina, PA
209 Ball Park St
BENNETTSVILLE, SC 29512
(704)323-2000
Urology
Montgomery Urology Clinic
1001 N Main Street
P.O. Box J
Troy, NC 27371
(910)572-3900
John A Smid, MD
Montgomery County
General Surgery
522 Allen St
Ste 203
Troy, NC 27371
(910)571-5710
Fabian E Alzamora, MD
*
Prithvi Hanspal, MD
*
*
A - 25
October 2012
Moore County
Cardiology
Allergy/Immunology
205 Page Rd
Pinehurst, NC 28374
(910)295-5511
Allergy Partners of Pinehurst
325 Page Rd, Bldg 3
PO Box 5547
Pinehurst, NC 28374
(910)295-6661
Edward Scott Anderson, DO
David M Cowherd, MD
Gurvinder K Deogun, MD
Keith E Davis, MD
Carla J Luna, MD
Joseph F Hakas, Jr, MD
Vaishali S Mankad, MD
Lukas Jantac, MD
Steven M Kent, MD
Cardiac/Thoracic Surgery
FM Simmons Patterson, Jr, MD
FH Cardiovascular & Thoracic
155 Memorial Dr
(910)715-4111
Cardiology Electrophysiology
205 Page Rd
Pinehurst, NC 28374
(910)295-5511
Thomas Arthur Edgerton, MD
Peter I Ellman, MD
John F Krahnert, MD
Andrew M Shirlen, PAC
Rodrigo A Bolanos, MD
Cardiology
Ker Boyce, MD
FH Cardiology Services
155 Memorial Dr
Pinehurst, NC 28374
(910)715-7560
Chiropractic
First Chiropractic
1701 N Sandhills Blvd
Ste D
Aberdeen, NC 28315
(910)944-7889
Steven J Filby, MD
Gary P Dackor, DC
A - 26
*
October 2012
Dermatology
General Surgery
Carolina Skin Care, PA
125 Fox Hollow Rd
Ste 210
Pinehurst, NC 28374
(910)295-7546
5 FirstVillage Dr
PO Box 2000
Pinehurst, NC 28374
(910)295-0290
David I Klumpar, MD
*
Huey Willy Chu, MD
Pinehurst Dermatology, PA
185 Page Rd
Ste A
Pinehurst, NC 28374
(910)295-5567
John M Fessenden, MD
David W Grantham, MD
Amelia M Jeyapalan, MD
Robert Clayton Steiner, MD
Raymond G Washington, Jr, MD
Reynold Carter Grine, MD
Pamela J Guest, MD
Hematology/Oncology
Endocrinology
FirstHealth Outpatient Cancer Center
220 Page Rd
Pinehurst, NC 28374
(910)715-3500
205 Page Rd
Pinehurst, NC 28374
(910)295-5511
Charles S Kuzma, MD
Robert A Pohlmeyer, MD
Brooks B Mays, MD
Ellen M Willard, MD
Olga V Ostmann, MD
251 Campground Rd
WEST END, NC 27376
(910)715-6100
Gastroenterology
15 Regional Dr
(910)255-4400
Charles S Kuzma, MD
Todd A Moore, MD
Ellen M Willard, MD
Eric R Frizzell, MD
Wayne B Lucas, MD
David F Martin, MD
Thomas M Swantkowski, MD
Ravikant V Varanasi, MD
Diane M Williams, MD
A - 27
October 2012
Internal Medicine
Neurosurgery
251 Campground Rd
WEST END, NC 27376
(910)715-6100
Carolina Neurosurgical Services
5 FirstVillage Dr
Pinehurst, NC 28374
(910)295-0215
William P Cleaver, MD
Larry V Carson, MD
Nephrology
Carol M Wadon, MD
Pinehurst Nephrology Associates, PC
293 Olmsted Blvd
Ste 7
Pinehurst, NC 28374
(910)295-3344
Opthalmology
2170 Midland Rd
(910)295-2100
Edward W Hoehn-Saric, MD
John D Shepherd, MD
Jennifer K Stoddard, MD
Arghavan Almony, MD
Hanna Von Hardenberg, MD
Anna F Fakadej, MD
John W French, MD
Neurology
Neil B Griffin, MD
Pinehurst Neurology, PA
One Page Rd
PO Box 1749
Pinehurst, NC 28374
(910)295-6868
Jeffrey J White, MD
Jonathan M Richman, MD
Optometry
Misty L Sinclair, MD
2170 Midland Rd
(910)295-2100
Robert D Snyder, MD
Bruce S Solomon, DO
Carson C Cox, OD
Joey L Harris, OD
Katie C Hickman, OD
John D Miller, OD
A - 28
October 2012
Orthopedic Surgery
Physical Medicine & Rehabilitation
Mid-South Orthopaedics
40 Aviemore Dr
Pinehurst, NC 28374
(910)295-4500
5 FirstVillage Dr
PO Box 2000
Pinehurst, NC 28374
(910)295-0290
Glen D Subin, MD
Kathleen M Eaton, MD
5 FirstVillage Dr
PO Box 2000
Pinehurst, NC 28374
(910)295-0290
Plastic Surgery
5 FirstVillage Dr
PO Box 2000
Pinehurst, NC 28374
(910)295-0290
Mark E Brenner, MD
David J Casey, MD
Neil A Conti, MD
David P Fedder, MD
Noel B McDevitt, MD
John R Moore, IV, MD
Russell B Stokes, MD
David E Strom, MD
Podiatry
*
Daniel M Williams, MD
Pinehurst Foot Specialist, PA
6 Regional Dr
Ste A
Pinehurst, NC 28374
(910)295-9255
Kurt P Wohlrab, MD
Otolaryngology
5 FirstVillage Dr
PO Box 2000
Pinehurst, NC 28374
(910)295-0290
Glenn H Dunlap, DPM
Jeanette R Johnson, DPM
Pulmonary Diseases
Carl W Berk, MD
205 Page Rd
Pinehurst, NC 28374
(910)295-5511
Stanley C Cox, III, MD
Waldemar L. Riefkohl, MD
Michael A Pritchett, DO
David C Thornton, MD
A - 29
October 2012
Radiation Oncology
Vascular Surgery
Moore Regional Hospital Radiation Oncology
Dept
155 Memorial Dr
Pinehurst, NC 28374
(910)715-1056
5 FirstVillage Dr
PO Box 2000
Pinehurst, NC 28374
(910)295-0290
Stephen C King, MD
*
Clinton K Atkinson, MD
Rheumatology/Immunology
Joel A Berman, MD
Lorraine Mayer-Wolpert Berman, MD
Pinehurst Rheumatology Clinic
4204 Murdocksville Rd
West End, NC 27376
(910)255-0055
Nash County
Cardiovascular Disease
Rex Physicians LLC
901 N Winstead Ave
Ste 44
Rocky Mount, NC 27804-8467
(252)937-0229
Kara Martin, MD
Karen H Schorn, MD
Urology
5 FirstVillage Dr
PO Box 2000
Pinehurst, NC 28374
(910)295-0290
James R Foster, MD
Orange County
Allergy/Immunology
Robert J Chamberlain, Jr, MD
101 Manning Dr
PO Box 168
(919)966-4131
Manlio Adam Goetzl, MD
Greg L Griewe, MD
William S Kizer, MD
Charles Rodney Lenahan, MD
Bernard M Stanfield, MD
Ravi R Jhaveri, MD
Geoffrey G White, MD
A - 30
October 2012
Cardiac/Thoracic Surgery
101 Manning Dr
PO Box 168
(919)966-4131
UNC Heart Center at Meadowmont
300 Meadowmont Circle
Ste 313
(919)966-7890
Aleida M Alvarez, PAC
James R Foster, MD
Michael E Bowdish, MD
Michael Yeung, MD
Tracy E Vernon-Platt, ANP
Dermatology
Cardiology
101 Manning Dr
PO Box 168
(919)966-4131
101 Manning Dr
PO Box 168
(919)966-4131
Timothy Flynn, MD
Aida M Lugo-Somolinos, MD
Kimberly D Guise, ANP
Dean Morrell, MD
J Larry Klein, MD
Susan S Runge, MD
Hemant Solomon, MBBS
Gastroenterology
Cardiology Electrophysiology
101 Manning Dr
PO Box 168
(919)966-4131
101 Manning Dr
PO Box 168
(919)966-4131
Danielle E Cardona, PAC
Kristen F Cole, NP
Ker Boyce, MD
Paul H Hayashi, MD
Ryan D Madanick, MD
Scott E Plevy, MD
A - 31
October 2012
General Surgery
Infectious Disease
101 Manning Dr
PO Box 168
(919)966-4131
101 Manning Dr
PO Box 168
(919)966-4131
Eleisha D Flanagan, MD
Suzanne M Blevins, ANP
Iman Ghaderi, MD
Joseph A Duncan, MD
Catherine T Stamey, PAC
Cynthia L Gay, MD
Corazon I Halsey, FNP
Geriatric Medicine
Jonathan J Juliano, MD
Judith Ng-Cashin, MD
101 Manning Dr
PO Box 168
(919)966-4131
Joseph D Tucker, MD
Neonatology
101 Manning Dr
PO Box 168
(919)966-4131
James B Holt, MD
Hematology/Oncology
101 Manning Dr
PO Box 168
(919)966-4131
Martin J McCaffrey, MD
Nephrology
101 Manning Dr
PO Box 168
(919)966-4131
Carey K Anders, MD
Walter C Baker, NP
Ethan M Basch, MD
Megan K Fuchs, PA
William Y Kim
Constance A Gilet, ANP
Matthew I Milowsky, MD
Jennifer G Vick, MD
Kristy L Richards, MD
Kaushik Sen, MD
Elizabeth T Sherwood, NP
A - 32
October 2012
Neurology
Optometry
101 Manning Dr
PO Box 168
(919)966-4131
101 Manning Dr
PO Box 168
(919)966-4131
Matthew A Englebrecht, MD
James B Baldwin, OD
Nansi M Greger-holt, FNP
Orthopedic Surgery
Raza L Khan, MD
Cheryl L McNeil, MD
101 Manning Dr
PO Box 168
(919)966-4131
Yael Shiloh-Malawsky, MD
Neurosurgery
101 Manning Dr
PO Box 168
(919)966-4131
Jeffrey T Spang, MD
Otolaryngology
101 Manning Dr
PO Box 168
(919)966-4131
Deb A Bhowmick, MD
Victor L Perry, MD
Opthalmology
101 Manning Dr
PO Box 168
(919)966-4131
Oliver F Adunka, MD
Peter G Chikes, MD
Brien R Pace, NP
Adam M Zanation, MD
George K Escaravage, MD
Kathleen B Gordon, MD
Odette M Houghton, MD
Sheel B Patel, MD
Cadmus C Rich, MD
Shashi K Sethi, MD
John G Tye, MD
A - 33
October 2012
Pediatrics
Plastic Surgery
101 Manning Dr
PO Box 168
(919)966-4131
101 Manning Dr
PO Box 168
(919)966-4131
Samantha A Borden, PNP
Kamil Erfanian, MD
Jennifer L Daniels, NP
Eric G Halvorsen, MD
Rani M Delaney, NNP
Pulmonary Diseases
Ajay S Gulati, NNP
Cherissa C Hanson, MD
101 Manning Dr
PO Box 168
(919)966-4131
Ann N Jessup, FNP
Michael D Kappelman, MD
David C Kwee, MD
Shipra Patel, MD
Rupa C Redding-lallinger, MD
Lydia H Chang, MD
Gregory H Tatum, MD
Paul M Dorinsky, MD
Stavros Garantziotis, MD
Ceila E Loughlin, MD
Physical Medicine & Rehabilitation
Molly A McCallum, FNP
101 Manning Dr
PO Box 168
(919)966-4131
Diane M Yorke, PNP
Radiation Oncology
101 Manning Dr
PO Box 168
(919)966-4131
Jongbae Park, MD
Paul Thananopavarn, MD
Glenda A Winchester, ANP
Achilles J Fakiris, MD
A - 34
October 2012
Radiology
Surgery
101 Manning Dr
PO Box 168
(919)966-4131
101 Manning Dr
PO Box 168
(919)966-4131
Courtney L Bui, MD
Keith D Amos, MD
Rachel D Aufforth, MD
Barbara M Birmingham, NP
Elizabeth B Dreesen, MD
101 Manning Dr
PO Box 168
(919)966-4131
Suzanne L Hartmann, NP
Samuel W Jones, MD
Patricia Lange, MD
Stanley R Mandel, MD
Timothy S Sadiq, MD
Kathryn M Baulk, PNP
Alexander H Toledo, MD
Maya R Jerath, MD
Urology
Carolina Pointe Physician Office
5915 Farrington Road
101 Manning Dr
PO Box 168
(919)966-4131
Claire V Chehrazi, MD
Timothy P Bukowski, MD
John S Wiener, MD
Vascular Surgery
101 Manning Dr
PO Box 168
(919)966-4131
Kathryn V Neece, PA
A - 35
October 2012
RANDOLPH County
Chiropractic
Opthalmology
First Choice Medical Group
921 E Broad Ave
(910)895-6042
220-C Foust St
ASHEBORO, NC 27203
(336)-62-9-14
Albert S Dreher, DC
Elizabeth K Gingrey, DC
Arghavan Almony, MD
Larry E Stogner, DC
Urology
Dermatology
Asheboro Urology Clinic
283 White Oak St
Asheboro, NC 27203
(336)625-3997
115 Medical Circle
(910)410-8380
*
Prithvi Hanspal, MD
*
David I Klumpar, MD
General Surgery
Richmond County
Audiology
Richmond Surgical Clinic, PA
921 Long Drive
Ste 206
(910)417-3410
Mid Carolinas Surgery Associates
921 Long Dr
Ste 208
(910)417-4368
Zeidan F Zeidan, MD
Theresa N Rogers, AUD
FirstHealth Richmond Medical Group-General
Surgery
921 S Long Dr
STE 208
(910)417-3540
Cardiology
Sandhills Cardiology Associates, PC
106 Physicians Park Dr
(910)895-7227
Huey Willy Chu, MD
Olujide G Lawal, MD
Robert C Parris, MD
*
A - 36
October 2012
Neurology
Urology
Scotland Neurology, PLLC
921 Long Dr
Rockingham, NC
Richmond Urology Clinic, PA
111 Mallard Lane
(910)997-5054
John K Mahon, MD
Hazem El-Droubi, MD
Orthopedic Surgery
FirstHealth Richmond Medical Group Orthopedic Clinic
809 S Long Drive
Ste K
(910)417-4090
809 S Long Drive
Ste K
(910)417-4090
David J Casey, MD
Robeson County
Neil A Conti, MD
Podiatry
David E Strom, MD
The Foot & Ankle Institute
815 Wesley Pines Rd
Lumberton, NC 28358
(910)737-6600
*
Kurt P Wohlrab, MD
Otolaryngology
Patrick J Ricotta, DPM
809 S Long Drive
Ste K
(910)417-4090
Sampson County
Rex Physicians LLC
603 Beaman St
Ste 5
Clinton, NC 28328-2650
(919)231-8253
Carl W Berk, MD
James R Foster, MD
A - 37
October 2012
Gastroenterology
403 Fairview St
CLINTON, NC 28328
(910)592-6011
Scotland Regional Health Network
205 F Lauchwood Dr
LAURINBURG, NC 28352-4604
John R Rice, MD
Sterling Surgical Services
500 Lauchwood Dr
(910)291-7000
Urology
Associated Urologists of NC, PA
350 Northeast Blvd
Clinton, NC 28328
(910)592-7129
Jerry A Jones, MD
General Surgery
William S Kizer, MD
Scotland Regional Health Network
1600 Medical Dr
(910)277-9164
Scotland County
Cardiology
Sandhills Cardiology Associates, PC
1705-A Berwick Dr
(910)610-4278
Stephen L Lanuti, MD
Olujide G Lawal, MD
Sterling Surgical Services
500 Lauchwood Dr
(910)291-7000
Robert C Parris, MD
Dermatology
Brian M Parkes, MD
*
Leslie J Salloum, MD
*
Chad D Caldwell, MD
103-A McAlpine Lane
(910)277-7546
Jason R Dameron, MD
Michael T Lake, MD
Frank Y Yang, MD
David I Klumpar, MD
A - 38
October 2012
Internal Medicine
Opthalmology
Jeffrey A Moore, MD, Inc
215 B Lauchwood Dr
Laurinburg, NC 28352-4647
(910)276-7727
514 S Main St
(910)276-4075
Jeffrey A Moore, MD
Anna F Fakadej, MD
Neurology
Optometry
Scotland Neurology, PLLC
704-A Progress Pl
(910)266-9876
514 S Main St
(910)276-4075
John K Mahon, MD
Carson C Cox, OD
Pinehurst Neurology, PA
815 S Main St
(910)277-0509
Orthopedic Surgery
OrthoCarolina, PA
1604 Medical Dr
(910)276-4611
Bruce S Solomon, DO
Occupational Medicine
Richard E Alexander, MD
Scotland Urgent Care
500 Lauchwood Dr
(910)277-8300
Ralph E Carter, III, MD
Paul F Rush, MD
John A Smid, MD
Phyllis M Wilson, PAC
James R Staten, MD
Otolaryngology
Opthalmology
Laurinburg ENT Clinic, PA
1705 B Berwick Dr
(910)610-4368
The Laser Eye Institute
1603 Medical Drive
Suite D
(910)277-1411
Kurt A Jute, DO
Mark K LaVigne, MD
*
A - 39
October 2012
Otolaryngology
Vascular Surgery
1705B Berwick Dr
(910)277-0509
Carolinas Vascular Associates
500 Lauchwood Dr
Laurinburg, NC 28352-5501
(910)291-7653
*
Physical Therapy
Joel A Berman, MD
Lorraine Mayer-Wolpert Berman, MD
OrthoCarolina, PA
1604 Medical Dr
(910)276-4611
Stanly County
Opthalmology
923 N 2nd St
Albemarle, NC 28001
(704)982-1000
William G Hatchell, PT
Charles E Jackson, PT
Podiatry
Arghavan Almony, MD
The Foot & Ankle Institute
103 McAlpine Lane
(910)266-9900
Andrew T Billingsley, MD
Neil B Griffin, MD
Wake County
Urology
Allergy/Immunology
Scotland Urology, PA
1603 C Medical Dr
(910)277-8636
Allergy Partners, PA
10010 Falls of Neuse Rd
Ste 106
Raleigh, NC 27614
(919)846-0800
Antonios Z Karamalegos, MD
A - 40
October 2012
Pediatrics
Rex Physicians LLC
3000 New Bern Ave
Ste G-100
Raleigh, NC 27610-1231
(919)231-8253
NC Children's Specialty Clinic
4414 Lake Boone Trail
Ste 505
Raleigh, NC 27607
(919)783-7809
James R Foster, MD
Ajay S Gulati, NNP
Dermatology
Cary Skin Center PA
200 Wellesley Trade Lane
Cary, NC 27519-5576
(919)936-3754
Urology
105 SW Cary Pkwy
Ste 300
Cary, NC 27511
(919)467-3203
Timothy Flynn, MD
Otolaryngology
William S Kizer, MD
Central Carolina ENT Associates, PA
1011 W Williams St
Ste 106
Apex, NC 27502
(919)363-9311
160 MacGregor Pines Dr
Ste 205
Cary, NC 27511
(919)851-5482
Doris Lin, MD
2800 Blue Ridge Rd
Raleigh, NC 27607
(919)851-5482
Pediatrics
Carolina Children's Cardiology
3000 New Bern Ave
Ste G-200
Raleigh, NC 27610
(919)350-8766
2801 Blue Ridge Rd
Ste 110
Raleigh, NC 27607-8714
(919)758-8677
Gregory H Tatum, MD
A - 41
October 2012
Hospitals
Medical Equipment & Supplies
Lee County
County
Central Carolina Hospital
1135 Carthage St
Sanford, NC 27330
Value Medical
107 Kiowa Ln
Piedmont, SC 29673
(800)861-4965
Montgomery County
Alamance County
FirstHealth Montgomery Memorial Hospital
522 Allen St
Troy, NC 27371
(910)571-5000
Alamance Eye Prosthetics, Inc
1736 Maple Ave
Burlington, NC 27215
(336)228-1403
Moore County
Moore County
FirstHealth Moore Regional Hospital
155 Memorial Dr
PO Box 3000
Pinehurst, NC 28374
(910)715-1000
Orthotics & Prosthetics of Pinehurst
165 Page Rd
Ste 4
Pinehurst, NC 28374
(910)295-4489
Orange County
Orange County
University of North Carolina Hospitals
101 Manning Dr
(919)966-7890
Atlantic Prosthetics & Orthotics
200 timberhill PL
Ste 203
Richmond County
Richmond County
FirstHealth Richmond Memorial Hospital
921 Long Dr
(910)417-3000
Mabrys Drug Store
140 Main Street
Hamlet, NC 28345
(910)582-1776
Scotland County
Stanly County
Scotland Memorial Hospital
500 Lauchwood Dr
(910)921-7000
Alliance Medical inc
907 N 2nd St
Albemarle, NC 28001
(704)983-5644
A - 42
October 2012
Other Outpatient Services
Surry County
Montgomery County
Prism Medical Products
112 Church St
Ste 101
Elkin, NC 28621-3476
(888)244-6421
Davita, inc
323 W Main St
Biscoe, NC 27209
Moore County
Surgery Center of Pinehurst
10 First Village Dr
Pinehurst, NC 28374
(910)235-5000
Home Health Care
Lee County
FirstHealth Home Care
109-A South Vance Street
Sanford, NC 27330
(800)876-2212
Davita, inc
16 Regional Dr
Pinehurst, NC 28374
Moore County
Davita, inc
165 Savannah Gardens Dr
Carthage, NC 28327
FirstHealth Home Care
181A Westgate Dr
West End, NC 27376
(910)295-2211
Davita, inc
209 Windstar Pl
Richmond County
FirstHealth Home Care Richmond
928 S Long Dr
Richmond County
Davita, inc
771 Cheraw Rd
Hamlet, NC 28345
Cook County
LifeWatch Services Inc.
10255 W Higgins Rd
Ste 100
Rosemont, IL 60018
(866)804-3623
Scotland County
Bio-Medical Applications of NC, Inc
1061 Aberdeen Rd
(781)699-4144
Hoke County
Davita, inc
403 S Main St
Raeford, NC 28376
A - 43
October 2012
Bio-Medical Applications of NC, Inc
507 Lauchwood Dr
(781)699-4144
Wake County
Spectrum Infusion, Inc
2601 Blue Ridge Rd
Ste A
Raleigh, NC 27607
(919)781-2241
Skilled Nursing Facilities
Moore County
St. Joseph of the Pines
103 Gossman Dr
(910)246-1000
ManorCare of Pinehurst NC, LLC
205 Rattlesnake Trail
Pinehurst, NC 28374
(910)295-1781
A - 44
October 2012
Network Provider Directory
Provider Index
23, 38
Oliver F Adunka, MD
33
Ajay K Ajmani, MD
Richard E Alexander, MD
4
25, 30, 40
39
Arghavan Almony, MD
28, 36, 40
Aleida M Alvarez, PAC
30, 31
25, 27, 36
Enobong Amao, MD
2
William S Boyd, PAC
20
Keith D Amos, MD
35
Carey K Anders, MD
32
Edward Scott Anderson, DO
26
Michael A Antil, MD
6, 7
Gregory C Appert, MD
12
Don M Armstrong, MD
15
Sonal Arora, MD
24
Behnam Asgharian, MD
23
Gary N Asher, MD
7, 8
Nasser A Askary, MD
15
Mahmoud K Atieh, MD
22
Rachel D Aufforth, MD
Linda J Aycock, LPC
30, 40
35
17, 18
Johnny W Bagwell, MD
12
Walter C Baker, NP
32
James B Baldwin, OD
33
6
Daniel R Barnes, DO
7
Ethan M Basch, MD
32
Julie G Baugher, MD
6, 7
Kathryn M Baulk, PNP
35
10/03/2012
Provider Index
Alice D Beane, FNP
5
Karen J Behling, MD
9
Susan M Berendzen, MD
8
Carl W Berk, MD
Molly C Berkoff, MD
24, 25, 29, 37
9
Joel A Berman, MD
30, 40
Lorraine Mayer-Wolpert Berman,
MD
30, 40
Nancy L Berson, LCSW
19
Deb A Bhowmick, MD
33
Andrew T Billingsley, MD
40
Jeffrey N Binney, MD
Barbara M Birmingham, NP
6, 7
35
Greg M Blakely, MD
6, 7
Kathryn J Bland, NP
12
Suzanne M Blevins, ANP
32
James G Blount, MD
Wanda J Boggs, FNP
Rodrigo A Bolanos, MD
Samantha A Borden, PNP
Lyse Bourguignon, LCSW
Amy Bouthilette, LDN
Michael E Bowdish, MD
Melva R Bowman, MD
Ker Boyce, MD
8
16, 17
8
26
33, 34
19
8
31
14, 15
10
26, 31
Thomas D Brammer, MD
12
Deanna K Branscom, MD
9
Susan G Brassil, PA
5
Mark E Brenner, MD
29
10, 11
10/03/2012
Provider Index
Wallace Brown, MD
Barry K Buchele, MD
9
13, 14, 15
Michael Buebel, MD
8
Courtney L Bui, MD
35
35, 41
3
Andrew P Bush, MD
24
George D Bussey, MD
18
Erik S Butler, DO
4
John W Byron, MD
13, 14, 15
20, 25, 36
Jorge L Caceres, PA-C
2
Chad D Caldwell, MD
38
10
Danielle E Cardona, PAC
31
Larry V Carson, MD
Ralph E Carter, III, MD
David J Casey, MD
21, 28
39
25, 29, 37
30, 37
David L Chandler, DO
22
Lydia H Chang, MD
34
20, 23
Claire V Chehrazi, MD
35
Peter G Chikes, MD
33
Stephen K Chiu, MD
Jiho Choi, MD
7, 10
2
Huey Willy Chu, MD
22, 27, 36
Arlene E Chung, MD
8
Daniel Clarke-Pearson, MD
William P Cleaver, MD
Kristen F Cole, NP
15
27, 28
31
9
10/03/2012
Provider Index
Francis Farrell Collins, Jr, MD
Neil A Conti, MD
Lisa R Cowan, MD
David M Cowherd, MD
Carson C Cox, OD
7
24, 29, 37
22
22, 26
21, 23, 24, 28, 39
29, 37
Stephen H Cox, MD
3
Laura D Coyle, LPA
16, 17
Mary M Crowston, PhD
Carole M Crump, PAC
Randall S Crumpler, MD
David H Curl, PA
19
17, 18, 19
12
8
Karen J Cusack, PhD
19
Gary P Dackor, DC
26
Jason R Dameron, MD
38
16, 17
33, 34, 41
Jama M Darling, MD
Amir M Darwish, MD
Ian J Davis, MD
Keith E Davis, MD
10
9
22, 26
Margaret A Davis, CNM
13
Nancy K Davis, MSW
18
24, 41
Lyse M De Bourguignon, LCSW
19
Jennifer J Delaney, DO
13
Rani M Delaney, NNP
33, 34
Stephanie M Devane-Johnson, CNM
Darren Dewalt, MD
23
25, 26, 40
6, 7
15
8
10/03/2012
Provider Index
Andrea T DiMichele-Manes, MD
13
Elisabeth A Dinkins, FNP
15
Paul M Dorinsky, MD
34
Elizabeth B Dreesen, MD
35
Albert S Dreher, DC
36
16, 17
Joseph A Duncan, MD
32
Glenn H Dunlap, DPM
29
Kathleen M Eaton, MD
29
Suzanne E Eaton-Jones, MD
12
Mary H Edge, LCSW
Thomas Arthur Edgerton, MD
Hazem El-Droubi, MD
Chrystal F Eller, MD
17, 18, 19
26
20, 37
5
Peter I Ellman, MD
26
Matthew A Englebrecht, MD
33
Erin K Ennis, MD
12
Kamil Erfanian, MD
34
Dawn A Erikson, FNP
George K Escaravage, MD
Charles A Eure, MD
Linda M Evans, LCSW
Michael D Evers, MD
Anna F Fakadej, MD
4
33
4, 8
4
17, 18
15
23, 28, 39
Achilles J Fakiris, MD
34
Vickie L Farmer, PA-C
2
David P Fedder, MD
14, 15
11
25, 29
Cynthia K Feltner, MD
8
John M Fessenden, MD
27
10/03/2012
Provider Index
Steven J Filby, MD
26
Catherine Fine, CGC
8
Kim A Finlay-Tozzi, DO
4
Eleisha D Flanagan, MD
32
Kathryn R Flanagan, CCSW
19
Tiffany S Flanagan, MD
13
16, 17
Robert A Fleury, MD
18, 19
Timothy Flynn, MD
31, 41
James R Foster, MD
30, 31, 37, 41
Olin M Fox, MD
18, 19
16, 17
Ashleigh J Freeman, MD
10, 11
John W French, MD
20, 21, 28
Eric R Frizzell, MD
27
Megan K Fuchs, PA
32
Gary J Gala, MD
19
Stavros Garantziotis, MD
34
Camille M Gardner, MD
11
Dana L Garrett, MD
2, 4, 12
Sandeep S Gavankar, DO
8
Aaron M Gavett, DO
7
Cynthia L Gay, MD
32
Iman Ghaderi, MD
32
Elizabeth B Gibbons, MD
12
Gregory R Gibbons, MD
12
Joseph G Gibbons, DO
10
Jackson V Gibson, MD
6, 7
Constance A Gilet, ANP
32
Michael J Gillespie, MD
22
Elizabeth K Gingrey, DC
36
Manlio Adam Goetzl, MD
30
10/03/2012
Provider Index
Kathleen B Gordon, MD
33
Michael A Gordon, MD
23
Bruce T Granger, MD
David W Grantham, MD
Alfred Gray, LPC
Nansi M Greger-holt, FNP
Glenna L Grider, MD
Greg L Griewe, MD
Neil B Griffin, MD
8
27
16, 17
5, 6
33
4
25, 30
21, 28, 40
Jemma C Grindstaff, PhD
19
Reynold Carter Grine, MD
27
Pamela J Guest, MD
27
Kimberly D Guise, ANP
31
Ajay S Gulati, NNP
Joseph F Hakas, Jr, MD
34, 41
26
Daniel C Hall, MD
9
William E Hall, MD
4
Corazon I Halsey, FNP
32
Eric G Halvorsen, MD
34
Cherissa C Hanson, MD
34
Prithvi Hanspal, MD
20, 25, 36
Joey L Harris, OD
21, 24, 28
Elizabeth Harry, LCSW
18
Suzanne L Hartmann, NP
35
William G Hatchell, PT
40
Paul H Hayashi, MD
31
Paul M Heimbecker, MD
Todd E Helton, MD
16, 17
13
12, 13
Hans H Herfarth, MD
8
Laura A Hester, MD
8
10/03/2012
Provider Index
Katie C Hickman, OD
David E Hipp, MD
Edward W Hoehn-Saric, MD
20, 28
6, 7
28
Bryon J Hoffman, MD
James B Holt, MD
20, 23, 32
Jonathan W Homeister, MD
Odette M Houghton, MD
David A Howell, MD
Charles E Jackson, PT
33
5
14, 15
40
16, 17
21, 28
John W Jameson, III, MD
5
Lukas Jantac, MD
22, 26
21, 28
Maya R Jerath, MD
35
Ann N Jessup, FNP
34
Amelia M Jeyapalan, MD
27
Ravi R Jhaveri, MD
30
Jeanette R Johnson, DPM
29
Libre E Johnson, MD
8
Donald C Jones, MD
14, 15
17, 18, 19
Jason D Jones, MD
12
Jerry A Jones, MD
38
Lisa L Jones, MD
13
Mattie L Jones, PhD
Samuel W Jones, MD
17, 18, 19
35
Emily Y Joubert, CNM
8
Jonathan J Juliano, MD
32
Kurt A Jute, DO
13, 14
39
10/03/2012
Provider Index
Nadiya L Kaesemeyer, MD
19
Alexei B Kampov, LCSW
19
13, 14, 15
34, 41
Antonios Z Karamalegos, MD
40
Rita H Kelly, CNM
13
Steven M Kent, MD
22, 26
Jeffrey J Kern, PAC
2, 3, 9
16, 17
16, 17
Raza L Khan, MD
William Y Kim
Kelly Ennix King, MD
33
25, 29, 40
32
7
Stephen C King, MD
30
William S Kizer, MD
30, 38, 41
J Larry Klein, MD
David I Klumpar, MD
23, 31
27, 36, 38
Andre Knecht, DC
23
Julia S Knerr, MD
19
5, 9, 10
John F Krahnert, MD
26
Charles S Kuzma, MD
27
David C Kwee, MD
22, 34
Maria La Via, MD
19
Diane Krane Laber, MD
20
Michael T Lake, MD
38
Douglas E Lam, MD
5
Ashley K Lamb, MD
11
Jill J Lambert, MD
3
Patricia Lange, MD
35
Lauri K Langham, LCSW
19
10/03/2012
Provider Index
Stephen L Lanuti, MD
38
Mark K LaVigne, MD
39
Olujide G Lawal, MD
36, 38
Kristy Lee, CGC
Shelia A Leese-Roberts, LCSW
Charles Rodney Lenahan, MD
8
16
24, 41
30
6
Janet Ann Leone-Britt, PAC
5
Kathleen A Letizia, MD
6, 7
Moe R Lim, MD
Doris Lin, MD
Thomas H Lineberger, MD
24, 41
7
5, 10
Ceila E Loughlin, MD
34
Shelly S Lowery, MD
11
Garnett M Lowry, MD
2
Wayne B Lucas, MD
27
Aida M Lugo-Somolinos, MD
31
Carla J Luna, MD
21, 25, 26
24, 41
Veda W Lydon, LCSW
16
Ryan D Madanick, MD
31
John K Mahon, MD
37, 39
Stanley R Mandel, MD
35
Mary T Mandell, MD
18
John R Mangum, MD
Elizabeth A Manley, MSN
Matthew T Manzo, DO
Lynette A Mappes, LCSW
2
4, 6
26, 40
18
5
19
10/03/2012
Provider Index
David Margolis, MD
Laura Stutts Marks, NP
15
Amanda H Martin, ANP
10
David F Martin, MD
27
Kara Martin, MD
30
16, 17
Suzanne G Martin, PsyD
18
Daniel A Matthews, PAC
5
Bobby R Maynor, Jr, MD
7
Brooks B Mays, MD
27
Jack M McBride, MD
8
Martin J McCaffrey, MD
32
Robert D McCall, Jr, MD
23
Molly A McCallum, FNP
34
3
3
Noel B McDevitt, MD
17, 18, 19
29
2, 3
16
Cheryl L McNeil, MD
33
Philip M Mendys, PharmD
Benjamin K Merritt, MD
8
13
21, 28, 39
Lori A Meyerhoffer, MD
8
Patricia L Middleton, MD
16
Steven D Millen, ANP
10
23, 28
John D Miller, OD
21, 28
16, 17
Matthew I Milowsky, MD
32
20, 21, 22, 28, 40
10/03/2012
Provider Index
Michael Minozzi, MD
9
16
Artur G Mixa, MD
7
Dorothy B Mixa, MD
7
Philip G Mondi, MD
7
Carlton R Moore, MD
8
Jeffrey A Moore, MD
38, 39
29, 37
Todd A Moore, MD
Dean Morrell, MD
27
19, 31
Deborah L Morris, MD
2
Walter S Morris, III, MD
7
Vaishali R Nadkarni, MD
Lester D Nave, MD
14, 15
4
16, 17
4
Kathryn V Neece, PA
35
Judith Ng-Cashin, MD
32
Chuck T Nguyen, MD
2
6
John R Nobles, MD
3, 12
14
4, 5
Thomas L O'Connell, MD
Gerard J O'Donnell, MD
4
22, 29, 37
Robert G Oldroyd, MD
22
Rodolfo S Ongjoco, Jr, MD
18
Benjamin L Ose, MD
18
Olga V Ostmann, MD
27
Brien R Pace, NP
33
Lynn L Palin, LCSW
18
10/03/2012
Provider Index
Carrie Palmer, NP
8, 9
Jongbae Park, MD
34
Emily G Parker, PA
5
Brian M Parkes, MD
38
Robert C Parris, MD
36, 38
22, 26
Marion B Pate, III, MD
Jaimita V Patel, MD
Sheel B Patel, MD
23
2
21, 33
Shilpesh P Patel, MD
10
Shipra Patel, MD
34
FM Simmons Patterson, Jr, MD
26
Brenda L Pearson, LCSW
19
June L Peck, FNP
3
Victor L Perry, MD
33
Robert A Peterson, LPC
18
Victoria M Petrilli, LDN
19
Kevin R Pilecki, PA
24
Murali D Pisharody, MD
4
Theodore M Pitts, MD
24
Lawrence Burt Place, MD
22
Gregory T Pleasants, MD
12
Nancy J Plemmons, FNP
8
Scott E Plevy, MD
31
Robert A Pohlmeyer, MD
27
Leslie C Powell, CRNP
8
Elizabeth M Prata, FNP
8
Michael A Pritchett, DO
29
Ellen T Puleo, MD
15
7
Mizanur Rahman, MD
16, 17
Thomas J Raney, PhD
19
10/03/2012
Provider Index
Shane W Rau, MD
19
Mark D Raupp, MD
8
Sara A Reason, PNP
9
Rupa C Redding-lallinger, MD
Vonda H Reives, FNP
34
6
John R Rice, MD
38
Cadmus C Rich, MD
33
Kristy L Richards, MD
32
Jonathan M Richman, MD
28
14, 16
37, 40
Waldemar L. Riefkohl, MD
Fabian D Rodriguez, MD
29
7
Heather A Rogers, MD
19
Theresa N Rogers, AUD
36
Mary T Roth, PharmD
Daniel L Rowland, MD
14, 15
Jonathan Rowson, MD
5, 11
David R Rubinow, MD
19
David C Ruck, MD
Sarah C Ruff, MD
18, 19
8
Susan S Runge, MD
31
Paul F Rush, MD
39
Timothy S Sadiq, MD
35
3, 4
Leslie J Salloum, MD
38
Saul A Salvador, MD
7
Lauren K Samford, CPP
21
Heather B Scheffler, PhD
17
Karen H Schorn, MD
30
Tina H Scott, FNP
12
Carl J Seashore, MD
9
10/03/2012
Provider Index
Kaushik Sen, MD
32
Shashi K Sethi, MD
33
Mohammed Sharouk Khader, MD
10
John D Shepherd, MD
28
Elizabeth T Sherwood, NP
32
Yael Shiloh-Malawsky, MD
33
26, 31
21, 28, 40
Rebecca S Siegel, PhD
Ovidiu Gabriel Silasi, MD
19
7
22, 26
Misty L Sinclair, MD
28
Van Slaughter, Jr, MD
7
Philip D Sloane, MD
8
John A Smid, MD
Karen L Smith, MD
25, 39
3
Robert D Snyder, MD
28
Jair C Soares
19
Michael F Soboeiro, MD
Bruce S Solomon, DO
7
28, 39
Hemant Solomon, MBBS
31
John T Soper, MD
15
16, 17
Jeffrey T Spang, MD
33
David E Spivey, MD
12
Matthew T Sproul, MD
8
Catherine T Stamey, PAC
32
Bernard M Stanfield, MD
30
3
Michol Stanzione, DO
6
Ellen B Starnes, LCSW
18
Sheryl Starnes, MD
2, 9
10/03/2012
Provider Index
James R Staten, MD
39
Anne Z Steiner, MD
15
27, 36
8, 9
Jennifer K Stoddard, MD
28
Larry E Stogner, DC
36
Russell B Stokes, MD
29
David E Strom, MD
29, 37
Gretchen S Stuart, MD
15
Alison M Stuebe, MD
15
Glen D Subin, MD
29
Denise H Sutherland-Phillips, MD
Thomas M Swantkowski, MD
Stephen A Szabo, MD
Jennifer G Szurgot, MD
Gregory H Tatum, MD
Valerie D Taylor, PA-C
Teresa Terezis, MD
William V Terry, MD
8
18, 19
27
13, 14, 15
7
34, 41
2
13
13, 14, 15
Paul Thananopavarn, MD
34
Julie M Thomas, PA-C
10
Robert L Thomas, PA-C
5
David C Thornton, MD
17, 18, 19
29
21, 28
Brian K Thwaites, MD
24
Alexander H Toledo, MD
35
Anthony Tonos, MD
10
Brian C Torgerson, MD
4
Robert G Townsend, III, DO
2
Joseph A Tozzi, MD
4
10/03/2012
Provider Index
Joseph D Tucker, MD
32
Habiba Tunau, MD
11
John G Tye, MD
33
Michael J Tyler, MD
13, 14
Padiwath C Ung, MD
7
Touber Vang, MD
5
Ravikant V Varanasi, MD
27
Sangeeta C Varanasi, MD
6
Tracy E Vernon-Platt, ANP
31
Jennifer G Vick, MD
32
Gail A Vincent, PhD
17
Hanna Von Hardenberg, MD
28
Carol M Wadon, MD
Amy Walsh, MD
21, 28
12
7
17, 18, 19
Raymond G Washington, Jr, MD
27
Elizabeth M Watson, PMH-NP
18
Lynn M Wegner, MD
9, 13
Wendell D Wells, MD
10
Geoffrey G White, MD
30
Jeffrey J White, MD
21, 22, 28
Paul W Whitecar, MD
14
Donna M Wiener, PhD
17, 18, 19
John S Wiener, MD
35
3, 5
Ellen M Willard, MD
27
Daniel M Williams, MD
29
Diane M Williams, MD
27
Kia Williams, MD
8, 12
Taneka M Williams, MD
11
Phyllis M Wilson, PAC
39
10/03/2012
Provider Index
Susan Kady Wilson, MD
14, 15
Glenda A Winchester, ANP
34
Jodi M Winkel, MD
12
James V Winkley, MD
24
Kurt P Wohlrab, MD
29, 37
11
5, 6
Frank Y Yang, MD
3
14, 15
38
Jen Jen Yeh, MD
Michael Yeung, MD
31
Diane M Yorke, PNP
34
Chassidy S Young, PA
4
Adam M Zanation, MD
33
Zeidan F Zeidan, MD
36
22, 34
13, 14, 15
Don L Zust, DO
12
10/03/2012
Additional Information:

FirstMedicare Direct is a health plan with a Medicare contract

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/coinsurance may change on January 1 of each year.

You must continue to pay your Medicare Part B premium

You must have both Medicare Part A and Medicare B to enroll

Other Pharmacies/Physicians/Providers are available in our network.

People with limited incomes may qualify for extra help to pay for their prescription
drug costs. If you qualify, Medicare could pay for 75% or more of your drug costs
including monthly prescription drug premiums, annual deductibles and coinsurance. Additionally, those who qualify will not be subject to the coverage gap
or a late enrollment penalty. Many people are eligible for these savings and don’t
even know it. For more information about this extra help, contact your local Social
Security office, or call Social Security at 1-800-772-1213. TTY users should call 1800-325-0778. You can also apply for extra help online at
www.socialsecurity.gov/prescriptionhelp.

Attend a FREE TalkAbout seminar in your area to get on-the-spot answers to your
questions and to learn more about options and opportunities with FirstMedicare
Direct. For dates and locations, visit www.FirstMedicare.com or call (800) 1234567. A sales person will be present at seminars with information and applications.
For accommodation of persons with special needs at seminars, call (800) 1234567. Meeting topics may include HMO and PPO plans.

Please contact a Sales representative at 1-877-279-1732 from October 1 February 14, 8 a.m. to 8 p.m., seven days a week, February 15 -September 30, 8
a.m. to 8 p.m., Monday through Friday.

Pre-Enrollment Book 2013 FirstMedicare Direct PPO Plus (PPO

Transcription

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