Fidelis Medicare Advantage Without Rx (HMO POS)
2016 Program Benefits Comparison Grid
This tool highlights our 2016 Medicare Advantage program benefits using a side-by-side layout so you can select the program that is right for you.
Personal Benefits Worksheet
Each year, you are asked to review your Medicare coverage to make your choices for the coming year. Fidelis Care offers an easy-to-use form to help you. Our Personal Benefits worksheet helps you with the key factors you need to consider when making your program selection and helps you understand your options so that you can make the best choices for your care.
Evidence of Coverage
This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2016. It explains how to get coverage for the health care services and prescription drugs you need.
Summary of Benefits
You can use this document to compare 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.
Out of Network Coverage Rules:
Under a Point of Service (POS) option, you may use non-plan providers to get your some covered services (see Section 2.4 for the definition of Point-of-Service in your Evidence of Coverage). However, your out of pocket costs may be higher if you use non-plan providers (for more information about this, see Section 2 in your Evidence of Coverage). The exception is if you use non-plan providers for emergency care.
Inpatient Acute Care
Inpatient Mental Health Care
Skilled Nursing Facility Care
Primary Care Physicians
Part B Prescription Drugs
Durable Medicare Equipment & Prosthetic Devices
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)
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.
The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan.
Limitations, copayments, and restrictions may apply.
Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.
This information is available for free in other languages. Please call our customer service number at 1-800-247-1447 (TTY: 1-800-695-8544). From October 1 to February 14, our office hours are 8:00 a.m. to 8:00 p.m. seven days a week. From February 15 through September 30, our office hours are Monday through Friday, 8:00 a.m. to 8:00 p.m.
Fidelis Care is an HMO plan with a Medicare contract. Enrollment in Fidelis Care depends on contract renewal.
Fidelis Care is a Coordinated Care plan with a Medicare contract and a contract with the New York State Department of Health Medicaid program. Enrollment in Fidelis Care depends on contract renewal.