Fidelis Care Bronze*+
Fidelis Care Bronze*+
Fidelis Care Silver*+
Fidelis Care Gold*+
Fidelis Care Platinum*+
BENEFITS
Standard
HSA-Compatible
Cost Sharing Reduction Options Available;
Enhanced Plan Option with Adult Dental
and Vision Available
Enhanced Plan Option with
Adult Dental and Vision 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)
$4,700
$6,100
$1,300
$600
$0
Max. Out of Pocket per Individual
(Family Max. is 2x Individual)
$8,700
$6,900
$8,500
$4,000
$2,000
Preventive Care**
$0
$0
$0
$0
$0
Primary Care Doctor Visit
$50 Copay for first three,
then $50 Copay after deductible
50% Coinsurance after deductible
$30 Copay after deductible
$25 Copay after deductible
$15 Copay
Specialist Doctor Visit
$75 Copay 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/CTScan/ PET Scan
$50 Copay after deductible
$75 Copay after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
$50 Copay per visit after deductible
$75 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
$50 Copay per visit 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
$150 Copay after deductible
50% Coinsurance after deductible
$150 Copay after deductible
$100 Copay after deductible
$100 Copay
Surgeon
$150 Copay after deductible
50% Coinsurance after deductible
$150 Copay after deductible
$100 Copay after deductible
$100 Copay
Inpatient Hospital – Acute
Inpatient Hospital – Mental Health
$1,500/admission after deductible
$1,500/admission after deductible
50% Coinsurance 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
$50 Copay after deductible
50% Coinsurance after deductible
$30 Copay after deductible
$25 Copay after deductible
$15 Copay
Skilled Nursing Facility
$1,500/admission after deductible
50% Coinsurance after deductible
$1,500/admission after deductible
$1,000/admission after deductible
$500 per admission
Emergency Room
$500 Copay after deductible
50% Coinsurance after deductible
$300 Copay after deductible
$150 Copay after deductible
$100 Copay
Urgent Care
$75 Copay after deductible
50% Coinsurance after deductible
$70 Copay after deductible
$60 Copay after deductible
$55 Copay
Ambulance
$300 Copay after deductible
50% Coinsurance after deductible
$150 Copay after deductible
$150 Copay after deductible
$100 Copay
PT/OT/ST
$50 Copay after deductible
50% Coinsurance after deductible
$30 Copay after deductible
$30 Copay after deductible
$25 Copay
Chiropractor
$75 Copay after deductible
50% Coinsurance after deductible
$50 Copay after deductible
$40 Copay after deductible
$35 Copay
Pediatric Eye Exams
Visits 1-3 covered,
then $50 after deductible
Visits 1-3 covered,
then $75 after deductible
$30 Copay after deductible
$25 Copay after deductible
$15 Copay
Pediatric Dental
$50 Copay after deductible
50% Coinsurance after deductible
$30 Copay after deductible
$25 Copay after deductible
$15 Copay
Durable Medical Equipment (DME)
50% Coinsurance after deductible
50% Coinsurance after deductible
30% Coinsurance after deductible
20% Cost Sharing after deductible
10% Coinsurance
Diabetic Supplies
$50 Copay 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
50% Coinsurance after deductible
50% Coinsurance after deductible
30% Coinsurance after deductible
20% Coinsurance after deductible
10% Coinsurance
Eyewear (Pediatric Only)
50% Coinsurance 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 (90-Day Supply)
$10 Copay after deductible
$35 Copay after deductible
$70 Copay after deductible
2.5x Retail Copay after deductible
$10 Copay after deductible
$35 Copay after deductible
$70 Copay after deductible
2.5x Retail Copay after deductible
$10 Copay
$35 Copay
$70 Copay
2.5x Retail Copay
$10 Copay
$35 Copay
$70 Copay
2.5x Retail Copay
$10 Copay
$30 Copay
$60 Copay
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 some 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 the
Essential Plan or a Qualified Health Plan 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 2021-2022, that period is from November 1, 2021 through January 31, 2022. New applicants
can enroll as early as November 1 through November 15, 2021 for December 2021 coverage and
November 16, 2021 through January 31, 2022 for 2022 coverage. 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.
-Telemedicine Program with Babylon: Covered services provided through Fidelis Care’s telemedicine
program with Babylon will be covered in full with no cost-sharing.
Fidelis Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national
origin, age, disability, or sex. Fidelis Care cumple con las leyes federales de derechos civiles aplicables y no discrimina por
motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Fidelis Care 遵守適用的聯邦民權法律規定 、不因種族 、
膚色 、民族血統 、年齡 、殘障或性別而歧視任何人。
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-888-343-3547 (TTY: 711).
注意：如果您使用繁體中文 、您可以免費獲得語言援助服務 。請致電 1-888-343-3547 (TTY: 711) 。
1-888-FIDELIS (1-888-343-3547)
TTY: 711 • fideliscare.org
FIDELIS CARE PRODUCT NOTES
Qualified
Health Plans
Bronze Bronze HSA Silver Gold Platinum
BENEFIT COMPARISON 2022
