Fidelis Care Catastrophic
Fidelis Care Bronze*+
Fidelis Care Silver*+
Fidelis Care Gold*+
Fidelis Care Platinum*+
BENEFITS
For those under Age 30 Only
Cost Sharing Reduction Options
Available
Monthly Premium
Varies by Rating Region
Varies by Rating Region
Varies by Rating Region
Varies by Rating Region
Varies by Rating Region
Deductible per Individual
(Family Deductible 2x Individual)
$7,350
$4,000
$2,000
$600
$0
Max. Out of Pocket per Individual
(Family Max. is 2x Individual)
$7,350
$7,150
$6,750
$4,000
$2,000
Preventive Care**
$0
$0
$0
$0
$0
Primary Care Doctor Visit
First three in a year covered in full,
then 100% Covered After Deductible
50% Coinsurance after deductible
$30 Copay after deductible
$25 Copay after deductible
$15 Copay
Specialist Doctor Visit
100% Covered After Deductible
50% Coinsurance after deductible
$50 Copay after deductible
$40 Copay after deductible
$35 Copay
Annual Physical Exam
$0
$0
$0
$0
$0
Clinical/Diagnostic Lab
X-ray/MRI/CT Scan/ PET Scan
100% Covered after deductible
100% Covered after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
$50 Copay per visit after deductible
$50 Copay per visit after deductible
$40 Copay per visit after deductible
$40 Copay per visit after deductible
$35 Copay per visit
$35 Copay per visit
Radiation Therapy
100% Covered after deductible
50% Coinsurance after deductible
$30 Copay per visit after deductible
$25 Copay per visit after deductible
$15 Copay per visit
Outpatient Facility - Surgery
100% Covered after deductible
50% Coinsurance after deductible
$100 Copay after deductible
$100 Copay after deductible
$100 Copay
Surgeon
100% Covered after deductible
50% Coinsurance after deductible
$100 Copay after deductible
$100 Copay after deductible
$100 Copay
Inpatient Hospital – Acute
Inpatient Hospital – Mental Health
100% Covered after deductible
50% Coinsurance after deductible
$1,500/admission after deductible
$1,500/ admission after deductible
$1,000/admission after deductible
$1,000/ admission after deductible
$500 per admission
$500 per admission
Outpatient Mental Health
100% Covered after deductible
50% Coinsurance after deductible
$30 Copay after deductible
$25 Copay after deductible
$15 Copay
Skilled Nursing Facility
100% Covered after deductible
50% Coinsurance after deductible
$1,500/admission after deductible
$1,000/admission after deductible
$500 per admission
Emergency Room
100% Covered after deductible
50% Coinsurance after deductible
$250 Copay after deductible
$150 Copay after deductible
$100 Copay
Urgent Care
100% Covered after deductible
50% Coinsurance after deductible
$70 Copay after deductible
$60 Copay after deductible
$55 Copay
Ambulance
100% Covered after deductible
50% Coinsurance after deductible
$150 Copay after deductible
$150 Copay after deductible
$100 Copay
PT/OT/ST
100% Covered after deductible
50% Coinsurance after deductible
$30 Copay after deductible
$30 Copay after deductible
$25 Copay
Chiropractor
100% Covered after deductible
50% Coinsurance after deductible
$50 Copay after deductible
$40 Copay after deductible
$35 Copay
Pediatric Eye Exams
100% Covered after deductible
50% Coinsurance after deductible
$30 Copay after deductible
$25 Copay after deductible
$15 Copay
Pediatric Dental
100% Covered after deductible
50% Coinsurance after deductible
$30 Copay after deductible
$25 Copay after deductible
$15 Copay
Durable Medical Equipment(DME)
100% Covered after deductible
50% Coinsurance after deductible
30% Coinsurance after deductible
20% Cost Sharing after deductible
10% Coinsurance
Diabetic Supplies
100% Covered after deductible
50% Coinsurance after deductible
$30 Copay, 30 Day Supply after
deductible
$25 Copay, 30 Day Supply after
deductible
$15 Copay, 30 Day Supply
Hearing Aids
100% Covered after deductible
50% Coinsurance after deductible
30% Coinsurance after deductible
20% Coinsurance after deductible
10% Coinsurance
Eyewear (Pediatric Only)
100% Covered after deductible
50% Coinsurance after deductible
30% Coinsurance after deductible
20% Coinsurance after deductible
10% Coinsurance
Prescription Drugs:
Generic – Tier 1
Preferred Brand – Tier 2
Non Preferred Brand – Tier 3
Mail Order
100% Covered after deductible
100% Covered after deductible
100% Covered after deductible
$10 Copay after deductible
$35 Copay after deductible
$70 Copay after deductible
90 Day Supply, 2.5x Retail Copay
after deductible
$10 Copay
$35 Copay
$70 Copay
90 Day Supply, 2.5x Retail Copay
$10 Copay
$35 Copay
$70 Copay
90 Day Supply, 2.5x Retail Copay
$10 Copay
$30 Copay
$60 Copay
90 Day Supply, 2.5x Retail Copay
Native American Option: A Native American who can show required documentation and earns less than 300% of the federal poverty level can choose a Silver, Gold, Platinum, or Bronze plan with no cost sharing.
+Child Only option available for this plan. Products not available in all areas. Please check with your Fidelis Care representative or visit fideliscare.org for information on products available in your area.
**For certain preventive care visits and services, as defined under section 2713 of the Affordable Care Act, there is 100% coverage with no cost sharing.
-Summary Only: This is a plan summary and is not intended to be comprehensive. Please
review the Summary Plan Description and Plan Document to get all of the details for your plan
of choice. In the event of differences between this summary and the Summary Plan Description
or Plan Document, the Plan Document will govern.
-Primary Care Doctor Selection Not Required: Selection of a primary care doctor to enroll in
a Health Benefit Exchange product is not required. However, we strongly encourage you to pick
a primary care doctor to assist you in managing your health.
-Network Only Benefits: Members enrolled in one of these products must use a doctor or
hospital that has a contract with Fidelis Care. These are known as “network providers.” There
are no benefits paid for medical services delivered by out-of-network providers, except in the
case of an emergency.
-Annual Open Enrollment Period: Enrollment in the plan is confined to an annual Open
Enrollment Period. In 2017-2018, that period is from November 1, 2017 through January 31,
2018. New applicants can enroll as early as November 1, 2017. Applications for coverage after
this period are possible with certain qualifying events.
-Effective Date of Coverage: Applications prior to the 15
th
of the month will be effective the
first of the following month. Applications after the 15
th
of the month will be effective the first of
the second month after application.
1-888-FIDELIS (1-888-343-3547)
TTY: 1-800-421-1220 • fideliscare.org
FIDELIS CARE PRODUCT NOTES
Metal-level
Products
Catastrophic Bronze Silver Gold Platinum
BENEFIT COMPARISON 2018
