Broker Resources

Fidelis Care plan materials:

HealthierLife Health and Recovery Plan (HARP)
Essential Plan

Treatment Cost Calculator


Essential Plan 1 

Benefit Summary (PDF)

Drug Formulary (PDF)

Subscriber Contract (PDF)


Essential Plan 2 

Benefit Summary (PDF)

Drug Formulary (PDF)

Subscriber Contract (PDF)


Essential Plan 3 

Benefit Summary (PDF)

Drug Formulary (PDF)

Subscriber Contract (PDF)


Essential Plan 4 

Benefit Summary (PDF)

Drug Formulary (PDF)

Subscriber Contract (PDF)

Metal-Level Products (Qualified Health Plans and Off-Exchange)

Medicare plan materials:

Fidelis Medicare Advantage Flex (HMO POS) Plan 022_001

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

Ежегодное уведомление об изменениях (PDF)

年度改變通知


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2020. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de cobertura (PDF)

Границы страховой ответственности (Evidence of Coverage) (PDF)

承保福利說明 (PDF)


Summary of Benefits

You can use this document to compare Fidelis Legacy Plan 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 2020 (PDF)

Краткий обзор страховых выплат на 2020 год (PDF)

2020年度福利介紹 (PDF)


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. 


Medicare requires that we have or arrange for enough providers to give you medically necessary plan covered services at the in-network cost-sharing level. This is called our "network" of providers. When you get services from non-plan providers, we call these "out-of-network" services. 


You don't need to get a referral when you get care from non-plan providers. However, before getting these services you may want to confirm with us that the services you are receiving are covered by us and are medically necessary. If we later determine that the services are not covered or were not medically necessary, we may deny coverage and you will be responsible for the costs. 


You will be allowed $10,000 worth of out-of-network services. Your cost-sharing amount for these services is $5,000. We will pay the other $5,000. Once the $10,000 maximum is met, you will be responsible for all costs associated with out-of-network care you receive.


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.

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. Hours are 8 AM to 8 PM. Member Services is available seven days per week between October 1 and March 31. For the period of April 1 to September 30, Member Services is available Monday through Friday.

Fidelis Medicare Advantage Without Rx (HMO POS) Plan 001

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

Ежегодное уведомление об изменениях (PDF)

年度改變通知


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2020. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de cobertura (PDF)

Границы страховой ответственности (PDF)

承保福利說明 (PDF)


Summary of Benefits

You can use this document to compare Fidelis Legacy Plan 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 2020 (PDF)

Краткий обзор страховых выплат на 2020 год (PDF)

2020年度福利介紹 (PDF)


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.

Medicare requires that we have or arrange for enough providers to give you medically necessary plan covered services at the in-network cost-sharing level. This is called our "network" of providers. When you get services from non-plan providers, we call these "out-of-network" services. 

You don't need to get a referral when you get care from non-plan providers. However, before getting these services you may want to confirm with us that the services you are receiving are covered by us and are medically necessary. If we later determine that the services are not covered or were not medically necessary, we may deny coverage and you will be responsible for the costs.

You will be allowed $10,000 worth of out-of-network services.  Your cost-sharing amount for these services is $5,000. We will pay the other $5,000. Once the $10,000 maximum is met, you will be responsible for all costs associated with out-of-network care you receive.

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.

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 copayments/coinsurance 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: 711). Hours are 8:00 a.m. to 8:00 p.m.  Member Services is available seven days per week between October 1 and March 31.  For the period of April 1 to September 30, Member Services is available Monday through Friday.
Fidelis Medicare Advantage $0 Premium (HMO) Plan 024_001

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

Ежегодное уведомление об изменениях (PDF)

年度改變通知


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2020. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de cobertura (PDF)

Границы страховой ответственности (PDF)

承保福利說明 (PDF)


Summary of Benefits

You can use this document to compare Fidelis Legacy Plan 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 2020 (PDF)

Краткий обзор страховых выплат на 2020 год (PDF)

2020年度福利介紹 (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 Fidelis Legacy Plan 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. 

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 copayments/coinsurance may change on January 1 of each year.

This information is available for free in other languages. Hours are 8 AM to 8 PM. Member Services is available seven days per week between October 1 and March 31. For the period of April 1 to September 30, Member Services is available Monday through Friday.

Fidelis Dual Advantage Flex (HMO SNP) Plan 017

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

Ежегодное уведомление об изменениях (PDF)

年度改變通知 (PDF)

 

Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2020. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de cobertura (PDF)

Границы страховой ответственности (PDF)

承保福利說明 (PDF)


Summary of Benefits

You can use this document to compare Fidelis Legacy Plan 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)

Краткий обзор страховых выплат (PDF)

福利介紹 (PDF)


Over-the-Counter Benefit Information


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 Fidelis Legacy Plan 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. 

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: 711). Hours are 8 AM to 8 PM. Member Services is available seven days per week between October 1 and March 31. For the period of April 1 to September 30, Member Services is available Monday through Friday.
Fidelis Dual Advantage (HMO SNP) Plan 002

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

Ежегодное уведомление об изменениях (PDF)

年度改變通知


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2020. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de cobertura (PDF)

Границы страховой ответственности (PDF)

承保福利說明 (PDF)


Summary of Benefits

You can use this document to compare Fidelis Legacy Plan 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)

Краткий обзор страховых выплат (PDF)

福利介紹 (PDF)


Over-the-Counter Benefit Information


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 Fidelis Legacy Plan 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. 

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: 711). Hours are 8 AM to 8 PM. Member Services is available seven days per week between October 1 and March 31. For the period of April 1 to September 30, Member Services is available Monday through Friday.
Medicaid Advantage Plus (HMO SNP) Plan 023_001

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

Ежегодное уведомление об изменениях (PDF)

年度改變通知


Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2020. It explains how to get coverage for the health care services and prescription drugs you need.

Evidence of Coverage (PDF)

Evidencia de cobertura (PDF)

Границы страховой ответственности (PDF)

承保福利說明 (PDF)


Summary of Benefits

You can use this document to compare Fidelis Legacy Plan 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)

Краткий обзор страховых выплат (PDF)

福利介紹 (PDF)


Over-the-Counter Benefit Information


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 Fidelis Legacy Plan 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. 

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: 711). Hours are 8 AM to 8 PM.  Member Services is available seven days per week between October 1 and March 31.  For the period of April 1 to September 30, Member Services is available Monday through Friday.

Questions? Commission Inquiries?

Call: 1-877-259-8428

Email: commissions@fideliscare.org
 

Statewide Contact: Gary Galletta, Broker Program Manager

Brokers must go to the broker manager to obtain an application.