Broker Resources

Fidelis Care plan materials:

Essential Plan
Formularies 

Essential Plan Resources

Virtual Support


2023 Summaries of Benefits and Coverage & Subscriber Contracts

Essential Plan 1 

 

Essential Plan 2 

Essential Plan 3 

 

Essential Plan 4 


2022 Summaries of Benefits and Coverage & Subscriber Contracts

Essential Plan 1 

 

Essential Plan 2 

Essential Plan 3 

 

Essential Plan 4 

Medicare 2022 Plan Documents | Wellcare By Fidelis Care

Wellcare Fidelis Dual Access (HMO D-SNP) Plan 001

Formulary

Covered Diabetes Meters and Testing Supplies


Over-the-Counter Benefit Information

 

Annual Notice of Changes

For Members Enrolled in Fidelis Dual Advantage Flex (Plan 001) in 2021

Annual Notice of Changes

Aviso Anual de Cambios

年度改變通知

변경 사항 연간 공지

 

Annual Notice of Changes

For Members Enrolled in Fidelis Dual Advantage (Plan 006) in 2021

Annual Notice of Changes

Aviso Anual de Cambios

年度改變通知

변경 사항 연간 공지


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2022. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage

Evidencia de Cobertura 

承保證明

보장 범위 증명서

Summary of Benefits

You can use this document to compare Wellcare By Fidelis Care Programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Summary of Benefits

Resumen de Beneficios

福利要點

혜택 요약서 (PDF)


Out of Network Coverage Rules

It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Wellcare By Fidelis Care authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage.

Wellcare Fidelis Assist (HMO-POS) Plan 002

Formulary

Covered Diabetes Meters and Testing Supplies


Over-the-Counter Benefit Information

 

Annual Notice of Changes

For Members Enrolled in Fidelis Dual Advantage Flex (Plan 002) in 2021

Annual Notice of Changes (PDF)

Aviso Anual de Cambios (PDF)

年度改變通知 (PDF)

변경 사항 연간 공지 (PDF)


Annual Notice of Changes

For Members Enrolled in Fidelis Dual Advantage Flex (Plan 007) in 2021

Annual Notice of Changes (PDF)

Aviso Anual de Cambios (PDF)

年度改變通知 (PDF)

변경 사항 연간 공지 (PDF)


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2022. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de Cobertura (PDF)

年度改變通知 (PDF)
*将于 11.15.2021 上传


Summary of Benefits

You can use this document to compare Wellcare By Fidelis Care programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Summary of Benefits (PDF)

Resumen de Beneficios 2022 (PDF)

福利要點 (PDF)

혜택 요약서 (PDF)


Out of Network Coverage Rules:

The following services are not covered out-of-network and you will be responsible for all of the costs if you obtain these services: 

Inpatient Acute Care 
Inpatient Mental Health Care 
Skilled Nursing Facility Care 
Primary Care Physicians 
Home Health 
X-rays 
Part B Prescription Drugs 
Durable Medicare Equipment & Prosthetic Devices 
Dialysis 
Outpatient Services including Surgery, X-rays, Outpatient Diagnostic Radiology (e.g. CT scans, PET scans, MRI's, nuclear medicine) and Therapeutic Radiology (e.g. radiation therapy, chemotherapy) 
Diabetic Supplies 

If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You will need to obtain “prior authorization” from us to get this care. In this situation, you will pay the same as you would pay if you got the care from a network provider. 

The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 of your Evidence of Coverage.

Wellcare Fidelis Dual Plus (HMO D-SNP) Plan 003

Formulary

Covered Diabetes Meters and Testing Supplies


Over-the-Counter Benefit Information

 

Annual Notice of Changes

Annual Notice of Changes

Aviso anual de cambios

年度改變通知

변경 사항 연간 공지


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2022. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage

Evidencia de Cobertura

承保證明

보장 범위 증명서


Summary of Benefits

You can use this document to compare Wellcare By Fidelis Care programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Summary of Benefits

Resumen de Beneficios

福利要點

혜택 요약서


Out-of-Network Coverage Rules

It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Wellcare By Fidelis Care authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage.

Wellcare Fidelis No Premium (HMO) Plan 004

Formulary

Covered Diabetes Meters and Testing Supplies


Over-the-Counter Benefit Information


 

Annual Notice of Changes

For Members Enrolled in Fidelis Medicare $0 Premium (Plan 004) in 2021

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

年度改變通知 (PDF)

변경 사항 연간 공지 (PDF)


Annual Notice of Changes

For Members Enrolled in Fidelis Medicare Advantage $0 Premium (Plan 009) in 2021

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

年度改變通知 (PDF)

변경 사항 연간 공지 (PDF)


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2022. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de Cobertura (PDF)

보장의 증거 (PDF)


Summary of Benefits

You can use this document to compare Wellcare By Fidelis Care programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Summary of Benefits (PDF)

Resumen de Beneficios 2021 (PDF)

福利要點 (PDF)

혜택 요약서 (PDF)


Out-of-Network Coverage Rules

It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Wellcare By Fidelis Care authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage.

Wellcare Fidelis Patriot No Premium (HMO-POS) Plan 005

Formulary

Covered Diabetes Meters and Testing Supplies

 

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

年度改變通知 (PDF)

변경 사항 연간 공지 (PDF)


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2022. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de Cobertura (PDF)

보장의 증거 (PDF)


Summary of Benefits

You can use this document to compare Wellcare By Fidelis Care programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Summary of Benefits (PDF)

Resumen de Beneficios 2022 (PDF)

福利要點 (PDF)

혜택 요약서 (PDF)


Out of Network Coverage Rules:

The following services are not covered out-of-network and you will be responsible for all of the costs if you obtain these services: 

Inpatient Acute Care 
Inpatient Mental Health Care 
Skilled Nursing Facility Care 
Primary Care Physicians 
Home Health 
X-rays 
Part B Prescription Drugs 
Durable Medicare Equipment & Prosthetic Devices 
Dialysis 
Outpatient Services including Surgery, X-rays, Outpatient Diagnostic Radiology (e.g. CT scans, PET scans, MRI's, nuclear medicine) and Therapeutic Radiology (e.g. radiation therapy, chemotherapy) 
Diabetic Supplies 

If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You will need to obtain “prior authorization” from us to get this care. In this situation, you will pay the same as you would pay if you got the care from a network provider. 

The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 of your Evidence of Coverage.

Wellcare Fidelis Dual Plus (HMO D-SNP) Plan 008

Formulary

Covered Diabetes Meters and Testing Supplies


Over-the-Counter Benefit Information

 

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso Anual de Cambios (PDF)

年度改變通知 (PDF)

변경 사항 연간 공지 (PDF)


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2022. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de Cobertura (PDF)

年度改變通知 (PDF)

보장 범위 증명서 (PDF)


Summary of Benefits

You can use this document to compare Wellcare By Fidelis Care programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Summary of Benefits (PDF)

Resumen de Beneficios (PDF)

福利要點 (PDF)

혜택 요약서 (PDF)


Out-of-Network Coverage Rules

It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Wellcare By Fidelis Care authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage.

Helpful Links

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Commission Inquiries?

Email: commissions@fideliscare.org

Phone: 1-877-259-8428

Statewide Contact

Statewide Contact Email: brokerservices@fideliscare.org

Brokers must email brokerservices@fideliscare.org to obtain an application.