** Cost ** |
Premium and Other Important Information |
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services |
$0 monthly plan premium in addition to your monthly Medicare Part B premium.* |
$6 700 out-of-pocket limit for Medicare-covered services.* |
$1 000 plan coverage limit every year for Non-Medicare Supplemental 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. |
Referral required for network specialists (for certain benefits). |
** Extra Benefits ** |
Over-the-Counter Items |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
Authorization rules may apply. |
$0 copay for up to 48 one-way trip(s) to plan-approved location every year |
** Important Information ** |
Premium and Other Important Information |
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services |
$0 monthly plan premium in addition to your monthly Medicare Part B premium.* |
$6 700 out-of-pocket limit for Medicare-covered services.* |
$1 000 plan coverage limit every year for Non-Medicare Supplemental benefits. Contact the plan for services that apply. |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network specialists (for certain benefits). |
** Inpatient Care ** |
Inpatient Hospital Care |
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 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. |
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. |
You will not be charged additional cost sharing for professional 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. Your plan will pay for a consultative visit before you select hospice. |
** Outpatient Care ** |
Doctor Office Visits |
0% or 20% of the cost for each Medicare-covered primary care doctor visit.* |
0% or 20% of the cost for each Medicare-covered specialist visit.* |
Chiropractic Services |
Authorization rules may apply. |
0% or 20% of the cost 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. |
Podiatry Services |
Authorization rules may apply. |
0% or 20% of the cost for each Medicare-covered podiatry visit* |
Medicare-covered podiatry visits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
0% or 35% of the cost for each Medicare-covered individual therapy visit* |
0% or 35% of the cost for each Medicare-covered group therapy visit* |
0% or 35% of the cost for each Medicare-covered individual therapy visit with a psychiatrist* |
0% or 35% of the cost for each Medicare-covered group therapy visit with a psychiatrist* |
0% or 20% of the cost for Medicare-covered partial hospitalization program services* |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered individual substance abuse outpatient treatment visits* |
0% or 20% of the cost for Medicare-covered group substance abuse outpatient treatment visits* |
Outpatient Services |
Authorization rules may apply. |
0% or 20% of the cost for each Medicare-covered ambulatory surgical center visit* |
0% or 20% of the cost for each Medicare-covered outpatient hospital facility visit* |
Ambulance Services |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered ambulance benefits.* |
Emergency Care |
$0 or $65 copay for Medicare-covered emergency room visits* |
0% or 20% of the cost (up to $65) for Medicare-covered emergency room visits* |
Worldwide coverage. |
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit. |
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit. |
Urgently Needed Care |
0% or 20% of the cost for Medicare-covered urgently-needed-care visits* |
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the urgently-needed-care visit. |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
There may be limits on physical therapy occupational therapy and speech and language pathology visits. If so there may be exceptions to these limits. |
0% or 20% of the cost for Medicare-covered Occupational Therapy visits* |
0% or 20% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits* |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered durable medical equipment* |
Prosthetic Devices |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered prosthetic devices* |
Diabetes Programs and Supplies |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered Diabetes self-management training* |
0% or 20% of the cost for Medicare-covered Diabetes monitoring supplies* |
0% or 20% of the cost for Medicare-covered Therapeutic shoes or inserts* |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
0% of the cost for Medicare-covered lab services* |
0% or 20% of the cost for Medicare-covered diagnostic procedures and tests* |
0% or 20% of the cost for Medicare-covered X-rays* |
0% or 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)* |
0% or 20% of the cost for Medicare-covered therapeutic radiology services* |
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of 0% or 20% of the cost may apply* |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of 0% or 20% of the cost may apply* |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
0% or 20% of the cost for Medicare-covered Cardiac Rehabilitation Services* |
0% or 20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services* |
0% or 20% of the cost for Medicare-covered Pulmonary Rehabilitation Services* |
Preventive Services and Wellness/Education Programs |
$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. |
The plan covers the following supplemental education/wellness programs: |
|
Additional Smoking and Tobacco Use Cessation Visits |
Health Club Membership/Fitness Classes |
Kidney Disease and Conditions |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered renal dialysis* |
0% or 20% of the cost for Medicare-covered kidney disease education services* |
Outpatient Prescription Drugs |
$0 yearly deductible for Medicare Part B drugs.* |
0% or 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.* |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.fideliscare.org 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 you the plan and Medicare. |
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 Dual Advantage Flex (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. |
The plan charges a minimum cost sharing amount for certain low-cost drugs. |
If you request a formulary exception for a drug and Fidelis Dual Advantage Flex (HMO SNP) approves the exception you will pay the generic cost share for generic drugs and the brand cost share for brand drugs. |
You pay a $0 annual deductible. |
Depending on your income and institutional status you pay the following: For generic drugs (including brand drugs treated as generic) either: - A $0 copay or
- A $1.15 copay or
- A $2.65 copay
For all other drugs either: - A $0 copay or
- A $3.50 copay or
- A $6.60 copay.
|
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. |
After your yearly out-of-pocket drug costs reach $4 750 you pay a $0 copay. |
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 Dual Advantage Flex (HMO SNP). |
Depending on your income and institutional status you will be reimbursed by Fidelis Dual Advantage Flex (HMO SNP) up to the plan’s cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic) either: - A $0 copay or
- A $1.15 copay or
- A $2.65 copay
For all other drugs purchased out-of-network either: - A $0 copay or
- A $3.50 copay or
- A $6.60 copay.
|
After your yearly out-of-pocket drug costs reach $4 750 you will be reimbursed in full for drugs purchased out-of-network. |
Dental Services |
Authorization rules may apply. |
$0 copay for the following preventive dental benefits: |
|
cleanings |
fluoride treatments |
dental x-rays |
0% or 20% of the cost for Medicare-covered dental benefits* |
Plan offers additional comprehensive dental benefits. |
Hearing Services |
$0 copay for: |
- supplemental routine hearing exams
|
fitting-evaluations for a hearing aid |
$0 copay for hearing aids. |
0% or 20% of the cost for Medicare-covered diagnostic hearing exams* |
** Additional Benefits ** |
Vision Services |
$0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye* |
$0 copay for up to 1 supplemental routine eye exam(s) every two years |
- up to 1 pair(s) of glasses every year
|
up to 1 pair(s) of contacts every year |
up to 1 pair(s) of lenses every year |
up to 1 frame(s) every year |
0% or 20% of the cost for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.* |
If the doctor provides you services in addition to eye exams separate cost sharing of 0% or 20% of the cost may apply* |
Over-the-Counter Items |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
Authorization rules may apply. |
$0 copay for up to 48 one-way trip(s) to plan-approved location every year |
Acupuncture |
$0 copay per acupuncture visit. |
** Inpatient Care ** |
Inpatient Hospital Care |
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. |
** Outpatient Care ** |
Doctor Office Visits |
0% or 20% of the cost for each Medicare-covered primary care doctor visit.* |
0% or 20% of the cost for each Medicare-covered specialist visit.* |
Outpatient Services |
Authorization rules may apply. |
0% or 20% of the cost for each Medicare-covered ambulatory surgical center visit* |
0% or 20% of the cost for each Medicare-covered outpatient hospital facility visit* |
Ambulance Services |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered ambulance benefits.* |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered durable medical equipment* |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
0% of the cost for Medicare-covered lab services* |
0% or 20% of the cost for Medicare-covered diagnostic procedures and tests* |
0% or 20% of the cost for Medicare-covered X-rays* |
0% or 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)* |
0% or 20% of the cost for Medicare-covered therapeutic radiology services* |
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of 0% or 20% of the cost may apply* |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of 0% or 20% of the cost may apply* |
** Additional Benefits ** |
Over-the-Counter Items |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
Authorization rules may apply. |
$0 copay for up to 48 one-way trip(s) to plan-approved location every year |