** Cost ** |
Premium and Other Important Information |
$30.4 monthly plan premium in addition to your monthly Medicare Part B premium. |
This plan covers all Medicare-covered preventive services with zero cost sharing. |
$6 700 out-of-pocket limit. |
This limit includes only Medicare-covered services. |
$625 plan coverage limit every year for Non-Medicare-covered benefits. Contact the plan for services that apply. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
No referral required for network doctors specialists and hospitals. |
** Extra Benefits ** |
Prescription Drugs |
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
$0 copay for home infusion drugs that would normally be covered under Part D. This cost-sharing amount will also cover the supplies and services associated with home infusion of these drugs. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.fidelissc.com/ourplans/t_partD.asp 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).
|
The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). 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 the 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 Fidelis Secure Comfort (HMO SNP) 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. |
$310 yearly deductible. |
After you pay your yearly deductible you pay 25% until total yearly drug costs reach $2 840. |
You can get drugs the following way(s): |
one-month (31-day) supply |
three-month (90-day) supply |
You can get drugs the following way(s): |
one-month (31-day) supply |
You can get drugs the following way(s): |
three-month (90-day) supply |
After your total yearly drug costs reach $2 840 you receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 550. |
After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of: - A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
- 5% coinsurance.
|
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 Fidelis Secure Comfort (HMO SNP). |
You can get drugs the following way: |
one-month (31-day) supply |
After you pay your yearly deductible you will be reimbursed up to 75% of the actual cost for drugs purchased out-of-network until your total yearly drug costs reach $2 840. |
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of: - A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
- 5% coinsurance.
|
Physical Exams |
$0 copay for routine exams. |
Limited to 1 exam(s) every year. |
Vision Services |
$0 copay for - one pair of eyeglasses or contact lenses after cataract surgery
|
glasses |
contacts |
lenses |
frames |
0% to 20% of the cost for exams to diagnose and treat diseases and conditions of the eye. |
0% of the cost for routine eye exams |
Dental Services |
$0 copay for Medicare-covered dental benefits. |
$0 copay for the following preventive dental benefits: |
oral exams |
cleanings |
dental x-rays |
Plan offers additional comprehensive dental benefits. |
** Important Information ** |
Premium and Other Important Information |
$30.4 monthly plan premium in addition to your monthly Medicare Part B premium. |
This plan covers all Medicare-covered preventive services with zero cost sharing. |
$6 700 out-of-pocket limit. |
This limit includes only Medicare-covered services. |
$625 plan coverage limit every year for Non-Medicare-covered benefits. Contact the plan for services that apply. |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
No referral required for network doctors specialists and hospitals. |
** Inpatient Care ** |
Inpatient Hospital Care (Acute) |
Plan covers 90 days each benefit period. |
You will not be charged additional cost sharing for professional services. |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
Inpatient Mental Health Care |
You get up to 190 days in a Psychiatric Hospital in a lifetime. |
Same deductible and copay as inpatient hospital care (see 'Inpatient Hospital Care') |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
Skilled Nursing Facility (SNF) |
Authorization rules may apply. |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
$0 copay for SNF services |
Home Health Care |
Authorization rules may apply. |
$0 copay for Medicare-covered home health visits. |
Hospice |
You must get care from a Medicare-certified hospice. |
** Outpatient Care ** |
Doctor Office Visits |
See 'Welcome to Medicare; and Annual Wellness Visit' for more information. |
Authorization rules may apply. |
$0 copay for each primary care doctor visit for Medicare-covered benefits. |
20% of the cost for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
Authorization rules may apply. |
20% of the cost for each Medicare-covered 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 or other qualified providers. |
Podiatry Services |
Authorization rules may apply. |
20% of the cost for each Medicare-covered visit. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
20% of the cost for each Medicare-covered individual or group therapy visit. |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
20% of the cost for Medicare-covered individual or group visits. |
Outpatient Hospital Services |
Authorization rules may apply. |
20% of the cost for each Medicare-covered ambulatory surgical center visit. |
20% of the cost for each Medicare-covered outpatient hospital facility visit. |
Emergency Care |
20% of the cost (up to $50) for Medicare-covered emergency room visits |
Not covered outside the U.S. except under limited circumstances. Contact the plan for more details. |
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit. |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
There may be limits on physical therapy occupational therapy and speech and language pathology services. If so there may be exceptions to these limits. |
$0 copay for Medicare-covered Occupational Therapy visits. |
$0 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. |
20% of the cost for Medicare-covered Cardiac Rehab services. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
20% of the cost for Medicare-covered items. |
Prosthetic Devices |
Authorization rules may apply. |
20% of the cost for Medicare-covered items. |
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies |
Authorization rules may apply. |
$0 copay for Diabetes self-monitoring training. |
$0 copay for Nutrition Therapy for Diabetes. |
20% of the cost for Diabetes supplies. |
** Preventive Services ** |
Bone Mass Measurement |
Authorization rules may apply. |
$0 copay for Medicare-covered bone mass measurement |
Colorectal Screening Exams |
Authorization rules may apply. |
$0 copay for Medicare-covered colorectal screenings. |
Immunizations |
Authorization rules may apply. |
$0 copay for Flu and Pneumonia vaccines. |
$0 copay for Hepatitis B vaccine. |
No referral needed for Flu and pneumonia vaccines. |
Pap Smears and Pelvic Exams |
Authorization rules may apply. |
$0 copay for Medicare-covered pap smears and pelvic exams. |
Prostate Cancer Screening Exams |
Authorization rules may apply. |
$0 copay for - Medicare-covered prostate cancer screening
|
** Additional Benefits ** |
Dialysis |
Authorization rules may apply. |
20% of the cost for renal dialysis |
$0 copay for Nutrition Therapy for End-Stage Renal Disease |
Prescription Drugs |
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
$0 copay for home infusion drugs that would normally be covered under Part D. This cost-sharing amount will also cover the supplies and services associated with home infusion of these drugs. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.fidelissc.com/ourplans/t_partD.asp 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).
|
The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). 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 the 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 Fidelis Secure Comfort (HMO SNP) 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. |
$310 yearly deductible. |
After you pay your yearly deductible you pay 25% until total yearly drug costs reach $2 840. |
You can get drugs the following way(s): |
one-month (31-day) supply |
three-month (90-day) supply |
You can get drugs the following way(s): |
one-month (31-day) supply |
You can get drugs the following way(s): |
three-month (90-day) supply |
After your total yearly drug costs reach $2 840 you receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 550. |
After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of: - A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
- 5% coinsurance.
|
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 Fidelis Secure Comfort (HMO SNP). |
You can get drugs the following way: |
one-month (31-day) supply |
After you pay your yearly deductible you will be reimbursed up to 75% of the actual cost for drugs purchased out-of-network until your total yearly drug costs reach $2 840. |
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of: - A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
- 5% coinsurance.
|
Dental Services |
$0 copay for Medicare-covered dental benefits. |
$0 copay for the following preventive dental benefits: |
oral exams |
cleanings |
dental x-rays |
Plan offers additional comprehensive dental benefits. |
Hearing Services |
$0 copay for hearing aids. |
20% of the cost for Medicare-covered diagnostic hearing exams |
0% of the cost for routine hearing tests |
0% of the cost for hearing aid fitting evaluations |
Vision Services |
$0 copay for - one pair of eyeglasses or contact lenses after cataract surgery
|
glasses |
contacts |
lenses |
frames |
0% to 20% of the cost for exams to diagnose and treat diseases and conditions of the eye. |
0% of the cost for routine eye exams |
Physical Exams |
$0 copay for routine exams. |
Limited to 1 exam(s) every year. |
Health/Wellness Education |
Authorization rules may apply. |
$0 copay for each Medicare-covered smoking cessation counseling session. |
$0 copay for each Medicare-covered HIV screening. |
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. |
Transportation |
Authorization rules may apply. |
$0 copay for up to 12 round trip(s) to plan-approved location every year. |
Acupuncture |
This plan does not cover Acupuncture. |