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		Fidelis Care Silver, Silver, ST, INN, Fidelis Care HBX Network, Pediatric Dental, Dep25, Free Telemedicine

Price Per Month	$524.45	Metal	Silver	Overall Quality Rating	Quality Details
Maximum Out of Pocket	$9,100 / $9100 per person \| $18200 per group	Out-of-Network Coverage	No	Allows Health Savings Account	No
Plan Id	25303NY0020001	Persons Covered	individual	Deductible	$1,750 / $1750 per person \| $3500 per group
Specialist(s) Referral Required No

Design	Fidelis Care members have direct access to a large network of quality providers throughout New York State. No referrals or paperwork are required to access Fidelis Care providers. Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots. Coverage for your child's dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals. Services obtained through Fidelis Care's Telemedicine program are covered free of charge.

Design

Fidelis Care members have direct access to a large network of quality providers throughout New York State. No referrals or paperwork are required to access Fidelis Care providers. Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots. Coverage for your child's dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals. Services obtained through Fidelis Care's Telemedicine program are covered free of charge.

Click on the benefit categories below to learn more about this plan's covered benefits and services. To see a full list of the benefits and services, visit the "Summary of Benefits" link under "Plan Documents" at the bottom of this page.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Transplant	$1650.00 Copay after deductible	100.00%	Transplants determined to be nonexperimental and non-investigational. Covered transplants include but are not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome. NOTE: Cost-share shown is the combined amount, including both the surgical fee and the Inpatient cost-share.
Second Opinion	$65.00 Copay after deductible	100.00%	A second medical opinion by an appropriate specialist or surgeon.
Telemedicine	No Charge	100.00%
Chemotherapy	$30.00 Copay after deductible	100.00%	Chemotherapy in an outpatient facility or in a Health Care Professional's office. Orally-administered anti-cancer drugs are covered under the prescription drug benefit.
Diabetic Equipment and Supplies	$30.00 Copay after deductible	100.00%
Family Planning Services	No Charge	100.00%	Counseling on the use of contraceptives, sterilization procedures, and related topics.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Urgent Care Centers or Facilities	$70.00 Copay after deductible	100.00%	A licensed facility (except Hospitals) that provides care for an illness, injury or condition serious enough to require care right away, but not so severe as to require emergency room care.
Emergency Room Services	$500.00 Copay after deductible	$500.00 Copay after deductible	Healthcare services you get in an emergency room.
Emergency Transportation/Ambulance	$150.00 Copay after deductible	100.00%	Ambulance services for an emergency medical condition.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Well Baby Visits and Care	No Charge	100.00%	Routine doctor visits for comprehensive preventive health services that occur when a baby is young.
Prenatal and Postnatal Care	No Charge	100.00%	Healthcare for expectant mothers before and after the birth of their child.
Preventive Care/Screening/Immunization	No Charge	100.00%	Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Gym Membership Reimbursement	Not Applicable	Not Applicable	Partial reimbursement for facility fees every 6 months if member attains at least 50 visits.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
X-rays and Diagnostic Imaging	$75.00 Copay after deductible	100.00%	X-rays and other technologies that doctors use in the diagnosis of a medical condition
Imaging (CT/PET Scans, MRIs)	$175.00 Copay after deductible	100.00%	Imaging technologies such as CT and PET Scans and MRIs that doctors use in the treatment of a medical condition
Laboratory Outpatient and Professional Services	$50.00 Copay after deductible	100.00%	Professional fees and services associated with laboratory work for diagnostic and treatment purposes.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Substance Abuse Disorder Outpatient Services	$30.00 Copay after deductible	100.00%	Also includes 20 visits per year for family counseling.
Mental/Behavioral Health Inpatient Services	$1500.00 Copay per Stay after deductible	100.00%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an inpatient setting.
Mental/Behavioral Health Outpatient Services	$30.00 Copay after deductible	100.00%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an outpatient setting.
Substance Abuse Disorder Inpatient Services	$1500.00 Copay per Stay after deductible	Not Applicable	Diagnosis and treatment of alcoholism and/or substance use and/or dependency in an inpatient setting. This includes coverage for detoxification and/or rehabilitation services as a consequence of chemical use and/or substance use.
Applied Behavior Analysis Based Therapies	$30.00 Copay after deductible	100.00%	Design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Home Health Care Services	$30.00 Copay after deductible	100.00%	Each visit of up to four hours by a home health aide is one visit.
Other Practitioner Office Visit (Nurse, Physician Assistant)	$30.00 Copay after deductible	100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	$150.00 Copay after deductible	100.00%
Outpatient Surgery Physician/Surgical Services	$150.00 Copay after deductible	100.00%	Surgical services performed by a physician or surgeon in an outpatient facility.
Primary Care Visit to Treat an Injury or Illness	$30.00 Copay after deductible	100.00%	Visit to a clinician for health services that cover a range of prevention, wellness, and treatment for common illnesses.
Specialist Visit	$65.00 Copay after deductible	100.00%	Visits to a physician to diagnose, manage, prevent or treat certain types of symptoms and conditions related to a specific disease or condition.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Outpatient Rehabilitation Services	$30.00 Copay after deductible	100.00%	60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.
Prosthetic Devices	30.00% Coinsurance after deductible	100.00%	1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices)
Chiropractic Care	$65.00 Copay after deductible	100.00%	Care performed by a Doctor of Chiropractic (Chiropractor).
Durable Medical Equipment	30.00% Coinsurance after deductible	100.00%	Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Inpatient Rehabilitation Services	$1500.00 Copay after deductible	100.00%	Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services consist of physical therapy, occupational therapy, and speech therapy in an inpatient setting.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Eye Glasses for Children	30.00% Coinsurance after deductible	100.00%	One prescribed lenses & frames in a 12-month period.
Routine Eye Exam for Children	$30.00 Copay after deductible	100.00%	Emergency, preventive and routine vision care for children.
Contact Lenses for Children	30.00% Coinsurance after deductible	100.00%	Standard prescription contact lenses once in any twelve (12) month period.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Basic Dental Care - Child	$30.00 Copay after deductible	100.00%	One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.
Major Dental Care - Child	$30.00 Copay after deductible	100.00%	Services, including procedures for treatment of diseased pulp chambers and pulp canals, where Hospitalization is not required, removable complete or partial dentures, including six (6) months follow-up care; and additional services include insertion of identification slips, repairs, relines and rebases and treatment of cleft palate.
Orthodontia - Child	$30.00 Copay after deductible	100.00%	Orthodontics used to help restore oral structures to health and function and to treat serious medical conditions for children.
Dental Check-Up for Children	$30.00 Copay after deductible	100.00%	Procedures which help prevent oral disease from occurring.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Non-Preferred Brand Drugs	$75.00	100.00%	Brand drugs are sold by a drug company under a specific name or trademark and is protected by a patent. Non-preferred drugs may or may not be included on a plan's covered drug list or formulary and have higher cost-share.
Preferred Brand Drugs	$40.00	100.00%	Brand drugs are sold by a drug company under a specific name or trademark and is protected by a patent. Preferred drugs are included on a plan's covered drug list or formulary.
Specialty Drugs	Not Applicable	Not Applicable	Specialty drugs are used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. The drugs are often self-injected or administered in a physician's office or through home health services.
Generic Drugs	$15.00	100.00%	A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Skilled Nursing Facility	$1500.00 Copay per Stay after deductible	100.00%	A facility that performs skilled nursing care and rehabilitation services provided on a continuous, daily basis.
Delivery and All Inpatient Services for Maternity Care	$1650.00 Copay after deductible	100.00%	Delivery and inpatient maternity care in a hospital for the mother, and inpatient newborn care in a hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery.
Inpatient Hospital Services (e.g., Hospital Stay)	$1500.00 Copay per Stay after deductible	100.00%	Health care you get when you're admitted as a patient to a health care facility, like a hospital or skilled nursing facility.
Inpatient Physician and Surgical Services	$150.00 Copay after deductible	100.00%	Surgical services performed by a physician or surgeon in an inpatient facility.

		Fidelis Care Silver, Silver, ST, INN, Fidelis Care HBX Network, Pediatric Dental, Dep25, Free Telemedicine

Price Per Month	$524.45	Metal	Silver	Overall Quality Rating
Quality Measure	Member Experience	Rating		Description	Based on member satisfaction surveys about their health care, doctors, and ease of getting appointments and services.
Quality Measure	Plan Administration	Rating		Description	Based on certain measures of how well a plan is run, including customer service, access to needed information, and network providers ordering appropriate testing and treatment.
Quality Measure	Medical Care	Rating		Description	Based on the plan's network providers improving or maintaining the health of its members with regular screenings, tests, vaccines, and monitoring of some conditions.
Maximum Out of Pocket	$9,100 / $9100 per person \| $18200 per group	Out-of-Network Coverage	No	Allows Health Savings Account	No
Plan Id	25303NY0020001	Persons Covered	individual	Deductible	$1,750 / $1750 per person \| $3500 per group
Specialist(s) Referral Required	No

Design	Fidelis Care members have direct access to a large network of quality providers throughout New York State. No referrals or paperwork are required to access Fidelis Care providers. Benefits include comprehensive coverage for hospitalization, surgery, prescription drugs, and 100% coverage for some preventive care services such as annual check-ups & flu shots. Coverage for your child's dental and vision care is also covered, as well as a gym reimbursement program to help you reach your fitness goals. Services obtained through Fidelis Care's Telemedicine program are covered free of charge.

Design

Other Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Transplant	$1650.00 Copay after deductible	100.00%	Transplants determined to be nonexperimental and non-investigational. Covered transplants include but are not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome. NOTE: Cost-share shown is the combined amount, including both the surgical fee and the Inpatient cost-share.
Second Opinion	$65.00 Copay after deductible	100.00%	A second medical opinion by an appropriate specialist or surgeon.
Telemedicine	No Charge	100.00%
Chemotherapy	$30.00 Copay after deductible	100.00%	Chemotherapy in an outpatient facility or in a Health Care Professional's office. Orally-administered anti-cancer drugs are covered under the prescription drug benefit.
Diabetic Equipment and Supplies	$30.00 Copay after deductible	100.00%
Family Planning Services	No Charge	100.00%	Counseling on the use of contraceptives, sterilization procedures, and related topics.

Emergency Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Urgent Care Centers or Facilities	$70.00 Copay after deductible	100.00%	A licensed facility (except Hospitals) that provides care for an illness, injury or condition serious enough to require care right away, but not so severe as to require emergency room care.
Emergency Room Services	$500.00 Copay after deductible	$500.00 Copay after deductible	Healthcare services you get in an emergency room.
Emergency Transportation/Ambulance	$150.00 Copay after deductible	100.00%	Ambulance services for an emergency medical condition.

Preventive and Wellness Services and Chronic Disease Management

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Well Baby Visits and Care	No Charge	100.00%	Routine doctor visits for comprehensive preventive health services that occur when a baby is young.
Prenatal and Postnatal Care	No Charge	100.00%	Healthcare for expectant mothers before and after the birth of their child.
Preventive Care/Screening/Immunization	No Charge	100.00%	Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Gym Membership Reimbursement	Not Applicable	Not Applicable	Partial reimbursement for facility fees every 6 months if member attains at least 50 visits.

Laboratory Outpatient and Professional Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
X-rays and Diagnostic Imaging	$75.00 Copay after deductible	100.00%	X-rays and other technologies that doctors use in the diagnosis of a medical condition
Imaging (CT/PET Scans, MRIs)	$175.00 Copay after deductible	100.00%	Imaging technologies such as CT and PET Scans and MRIs that doctors use in the treatment of a medical condition
Laboratory Outpatient and Professional Services	$50.00 Copay after deductible	100.00%	Professional fees and services associated with laboratory work for diagnostic and treatment purposes.

Mental Health and Substance Abuse Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Substance Abuse Disorder Outpatient Services	$30.00 Copay after deductible	100.00%	Also includes 20 visits per year for family counseling.
Mental/Behavioral Health Inpatient Services	$1500.00 Copay per Stay after deductible	100.00%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an inpatient setting.
Mental/Behavioral Health Outpatient Services	$30.00 Copay after deductible	100.00%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an outpatient setting.
Substance Abuse Disorder Inpatient Services	$1500.00 Copay per Stay after deductible	Not Applicable	Diagnosis and treatment of alcoholism and/or substance use and/or dependency in an inpatient setting. This includes coverage for detoxification and/or rehabilitation services as a consequence of chemical use and/or substance use.
Applied Behavior Analysis Based Therapies	$30.00 Copay after deductible	100.00%	Design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis

Outpatient Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Home Health Care Services	$30.00 Copay after deductible	100.00%	Each visit of up to four hours by a home health aide is one visit.
Other Practitioner Office Visit (Nurse, Physician Assistant)	$30.00 Copay after deductible	100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	$150.00 Copay after deductible	100.00%
Outpatient Surgery Physician/Surgical Services	$150.00 Copay after deductible	100.00%	Surgical services performed by a physician or surgeon in an outpatient facility.
Primary Care Visit to Treat an Injury or Illness	$30.00 Copay after deductible	100.00%	Visit to a clinician for health services that cover a range of prevention, wellness, and treatment for common illnesses.
Specialist Visit	$65.00 Copay after deductible	100.00%	Visits to a physician to diagnose, manage, prevent or treat certain types of symptoms and conditions related to a specific disease or condition.

Rehabilitative and Habilitative Services and Devices

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Outpatient Rehabilitation Services	$30.00 Copay after deductible	100.00%	60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.
Prosthetic Devices	30.00% Coinsurance after deductible	100.00%	1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices)
Chiropractic Care	$65.00 Copay after deductible	100.00%	Care performed by a Doctor of Chiropractic (Chiropractor).
Durable Medical Equipment	30.00% Coinsurance after deductible	100.00%	Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Inpatient Rehabilitation Services	$1500.00 Copay after deductible	100.00%	Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services consist of physical therapy, occupational therapy, and speech therapy in an inpatient setting.

Pediatric Vision

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Eye Glasses for Children	30.00% Coinsurance after deductible	100.00%	One prescribed lenses & frames in a 12-month period.
Routine Eye Exam for Children	$30.00 Copay after deductible	100.00%	Emergency, preventive and routine vision care for children.
Contact Lenses for Children	30.00% Coinsurance after deductible	100.00%	Standard prescription contact lenses once in any twelve (12) month period.

Pediatric Dental Care

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Basic Dental Care - Child	$30.00 Copay after deductible	100.00%	One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.
Major Dental Care - Child	$30.00 Copay after deductible	100.00%	Services, including procedures for treatment of diseased pulp chambers and pulp canals, where Hospitalization is not required, removable complete or partial dentures, including six (6) months follow-up care; and additional services include insertion of identification slips, repairs, relines and rebases and treatment of cleft palate.
Orthodontia - Child	$30.00 Copay after deductible	100.00%	Orthodontics used to help restore oral structures to health and function and to treat serious medical conditions for children.
Dental Check-Up for Children	$30.00 Copay after deductible	100.00%	Procedures which help prevent oral disease from occurring.

Prescription Drugs

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Non-Preferred Brand Drugs	$75.00	100.00%	Brand drugs are sold by a drug company under a specific name or trademark and is protected by a patent. Non-preferred drugs may or may not be included on a plan's covered drug list or formulary and have higher cost-share.
Preferred Brand Drugs	$40.00	100.00%	Brand drugs are sold by a drug company under a specific name or trademark and is protected by a patent. Preferred drugs are included on a plan's covered drug list or formulary.
Specialty Drugs	Not Applicable	Not Applicable	Specialty drugs are used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. The drugs are often self-injected or administered in a physician's office or through home health services.
Generic Drugs	$15.00	100.00%	A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs.

Hospitalization

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Skilled Nursing Facility	$1500.00 Copay per Stay after deductible	100.00%	A facility that performs skilled nursing care and rehabilitation services provided on a continuous, daily basis.
Delivery and All Inpatient Services for Maternity Care	$1650.00 Copay after deductible	100.00%	Delivery and inpatient maternity care in a hospital for the mother, and inpatient newborn care in a hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery.
Inpatient Hospital Services (e.g., Hospital Stay)	$1500.00 Copay per Stay after deductible	100.00%	Health care you get when you're admitted as a patient to a health care facility, like a hospital or skilled nursing facility.
Inpatient Physician and Surgical Services	$150.00 Copay after deductible	100.00%	Surgical services performed by a physician or surgeon in an inpatient facility.

Plan Documents

Customer Service	www.fideliscare.org
Summary of Benefits and Coverage	https://www.fideliscare.org/Member/Manage-Your-Plan/Member-Resources
Prescription Drug List	https://www.fideliscare.org/Provider/Provider-Resources/Pharmacy-Services
Provider Network	https://www.fideliscare.org/Find-A-Doctor
Plan Brochure	https://www.fideliscare.org/Shop-For-A-Plan/Our-Plans/Qualified-Health-Plans
Payment Information	https://members.fideliscare.org/initialpayment

Plan Details