Fidelis Copay

Posted : admin On 1/3/2022
Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the Fidelis Dual Advantage Flex (HMO D-SNP) (H5599 - 001) in Clinton, New York .
This plan is administered by NEW YORK QUALITY HEALTHCARE CORPORATION. To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the Fidelis Dual Advantage Flex (HMO D-SNP) health and prescription benefit details in chart format or email and view benefits chart
Plan Premium
The Fidelis Dual Advantage Flex (HMO D-SNP) has a monthly premium of $21.60. That is $259.20 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $21.60 montly premium is in addition to your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).
This Medicare Advantage Plan with Prescription Drug Coverage is a Local HMO plan.
Plan Membership
The Fidelis Dual Advantage Flex (HMO D-SNP) (H5599 - 001) currently has 42,104 members. There are 270 members enrolled in this plan in Clinton, New York.
Prescription Drug Coverage: Deductible, Cost-sharing, Formulary
This plan has a $445 deductible. So, you are 100% responsible for the first $445 in medication costs. After you have met the deductible, the Fidelis Dual Advantage Flex (HMO D-SNP) will share the costs of your medications with you -- see cost-sharing below. $445 is the maximum deductible for 2021. There are other plans with a lower deductible or even a $0 deductible for all formulary drugs. Click here to review plans with a $0 deductible.
The following information is about the Fidelis Dual Advantage Flex (HMO D-SNP) formulary (or drug list). There are 3168 drugs on the Fidelis Dual Advantage Flex (HMO D-SNP) formulary. Click here to browse the Fidelis Dual Advantage Flex (HMO D-SNP) Formulary.
The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Once you have spent $445, your initial coverage phase will start. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The Fidelis Dual Advantage Flex (HMO D-SNP)’s formulary is divided into 5 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:
  • Tier 1 (Preferred Generic) contains 452 drugs and has a co-payment of $0.00.
  • Tier 2 (Generic) contains 1,526 drugs and has a co-payment of $10.00.
  • Tier 3 (Preferred Brand) contains 313 drugs and has a co-insurance of 24% of the drug cost.
  • Tier 4 (Non-Preferred Drug) contains 256 drugs and has a co-insurance of 39% of the drug cost.
  • Tier 5 (Specialty Tier) contains 623 drugs and has a co-insurance of 25% of the drug cost.
Click here to browse the Fidelis Dual Advantage Flex (HMO D-SNP) Formulary.
The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 75% of your generic drug prescription costs in the donut hole on your behalf.
The brand-name drug manufacturer will pay 70% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 75% discount. The 70% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has 'No Gap Coverage'. This plan (Fidelis Dual Advantage Flex (HMO D-SNP)) offers No Coverage during the Coverage Gap phase.
The Fidelis Dual Advantage Flex (HMO D-SNP) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** Base Plan **
Premium
• Health plan premium: $0
• Drug plan premium: $21.60
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: Coming soon
• Other health plan deductibles: In-network: No
• Drug plan deductible: $445.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $7,550 In-network
Optional supplemental benefits
• No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary: 0% or 20% coinsurance per visit
• Specialist: 0% or 20% coinsurance per visit
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: 0% or 0-20% coinsurance (authorization required)
• Lab services: $0 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): 0% or 20% coinsurance (authorization required)
• Outpatient x-rays: 0% or 20% coinsurance (authorization required)
Emergency care/Urgent care
• Emergency: 0% or 20% coinsurance per visit (always covered)
• Urgent care: 0% or 20% coinsurance per visit (always covered)
Inpatient hospital coverage
• Coming soon (authorization required)
Outpatient hospital coverage
• 0% or 20% coinsurance per visit (authorization required)
Skilled Nursing Facility
• Coming soon (authorization required)
Preventive care
• $0 copay
Ground ambulance
• 0% or 20% coinsurance
Rehabilitation services
• Occupational therapy visit: 0% or 20% coinsurance (authorization required)
• Physical therapy and speech and language therapy visit: 0% or 20% coinsurance (authorization required)
Mental health services
• Inpatient hospital - psychiatric: Coming soon (authorization required)
• Outpatient group therapy visit with a psychiatrist: 0% or 20% coinsurance
• Outpatient individual therapy visit with a psychiatrist: 0% or 20% coinsurance
• Outpatient group therapy visit: 0% or 20% coinsurance
• Outpatient individual therapy visit: 0% or 20% coinsurance
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 0% or 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 0% or 20% coinsurance per item (authorization required)
• Diabetes supplies: $0 copay (authorization required)
Hearing
• Hearing exam: 0% or 20% coinsurance
• Fitting/evaluation: Not covered
• Hearing aids - inner ear: Not covered
• Hearing aids - outer ear: Not covered
• Hearing aids - over the ear: Not covered
Preventive dental
• Oral exam: $0 copay (limits apply)
• Cleaning: $0 copay (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s): $0 copay (limits apply)
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services: Not covered
• Restorative services: Not covered
• Endodontics: Not covered
• Periodontics: Not covered
• Extractions: Not covered
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
Vision
• Routine eye exam: $0 copay (limits apply)
• Other: Not covered
• Contact lenses: $0 copay (limits apply)
• Eyeglasses (frames and lenses): $0 copay (limits apply)
• Eyeglass frames: $0 copay (limits apply)
• Eyeglass lenses: $0 copay (limits apply)
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• $0 copay (limits apply)
Foot care (podiatry services)
• Foot exams and treatment: 0% or 20% coinsurance
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy: 0% or 20% coinsurance (authorization required)
• Other Part B drugs: 0% or 20% coinsurance (authorization required)
FidelisFidelis
Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the Fidelis Dual Advantage Flex (HMO D-SNP) (H5599 - 001) in Clinton, New York .
This plan is administered by NEW YORK QUALITY HEALTHCARE CORPORATION. To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the Fidelis Dual Advantage Flex (HMO D-SNP) health and prescription benefit details in chart format or email and view benefits chart
Plan Premium
The Fidelis Dual Advantage Flex (HMO D-SNP) has a monthly premium of $21.60. That is $259.20 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $21.60 montly premium is in addition to your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).
This Medicare Advantage Plan with Prescription Drug Coverage is a Local HMO plan.
Plan Membership
The Fidelis Dual Advantage Flex (HMO D-SNP) (H5599 - 001) currently has 42,104 members. There are 270 members enrolled in this plan in Clinton, New York.
Prescription Drug Coverage: Deductible, Cost-sharing, Formulary
This plan has a $445 deductible. So, you are 100% responsible for the first $445 in medication costs. After you have met the deductible, the Fidelis Dual Advantage Flex (HMO D-SNP) will share the costs of your medications with you -- see cost-sharing below. $445 is the maximum deductible for 2021. There are other plans with a lower deductible or even a $0 deductible for all formulary drugs. Click here to review plans with a $0 deductible.
The following information is about the Fidelis Dual Advantage Flex (HMO D-SNP) formulary (or drug list). There are 3168 drugs on the Fidelis Dual Advantage Flex (HMO D-SNP) formulary. Click here to browse the Fidelis Dual Advantage Flex (HMO D-SNP) Formulary.
The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Once you have spent $445, your initial coverage phase will start. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The Fidelis Dual Advantage Flex (HMO D-SNP)’s formulary is divided into 5 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:
  • Tier 1 (Preferred Generic) contains 452 drugs and has a co-payment of $0.00.
  • Tier 2 (Generic) contains 1,526 drugs and has a co-payment of $10.00.
  • Tier 3 (Preferred Brand) contains 313 drugs and has a co-insurance of 24% of the drug cost.
  • Tier 4 (Non-Preferred Drug) contains 256 drugs and has a co-insurance of 39% of the drug cost.
  • Tier 5 (Specialty Tier) contains 623 drugs and has a co-insurance of 25% of the drug cost.
Click here to browse the Fidelis Dual Advantage Flex (HMO D-SNP) Formulary.
The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 75% of your generic drug prescription costs in the donut hole on your behalf.
The brand-name drug manufacturer will pay 70% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 75% discount. The 70% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has 'No Gap Coverage'. This plan (Fidelis Dual Advantage Flex (HMO D-SNP)) offers No Coverage during the Coverage Gap phase.
The Fidelis Dual Advantage Flex (HMO D-SNP) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** Base Plan **
Premium
• Health plan premium: $0
• Drug plan premium: $21.60
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: Coming soon
• Other health plan deductibles: In-network: No
• Drug plan deductible: $445.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $7,550 In-network
Optional supplemental benefits
• No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary: 0% or 20% coinsurance per visit
• Specialist: 0% or 20% coinsurance per visit
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: 0% or 0-20% coinsurance (authorization required)
• Lab services: $0 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): 0% or 20% coinsurance (authorization required)
• Outpatient x-rays: 0% or 20% coinsurance (authorization required)
Emergency care/Urgent care
• Emergency: 0% or 20% coinsurance per visit (always covered)
• Urgent care: 0% or 20% coinsurance per visit (always covered)
Inpatient hospital coverage
• Coming soon (authorization required)
Outpatient hospital coverage
• 0% or 20% coinsurance per visit (authorization required)
Skilled Nursing Facility
• Coming soon (authorization required)
Preventive care
• $0 copay
Ground ambulance
• 0% or 20% coinsurance
Rehabilitation services
• Occupational therapy visit: 0% or 20% coinsurance (authorization required)
• Physical therapy and speech and language therapy visit: 0% or 20% coinsurance (authorization required)
Mental health services
• Inpatient hospital - psychiatric: Coming soon (authorization required)
• Outpatient group therapy visit with a psychiatrist: 0% or 20% coinsurance
• Outpatient individual therapy visit with a psychiatrist: 0% or 20% coinsurance
• Outpatient group therapy visit: 0% or 20% coinsurance
• Outpatient individual therapy visit: 0% or 20% coinsurance
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 0% or 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 0% or 20% coinsurance per item (authorization required)
• Diabetes supplies: $0 copay (authorization required)
Hearing
• Hearing exam: 0% or 20% coinsurance
• Fitting/evaluation: Not covered
• Hearing aids - inner ear: Not covered
• Hearing aids - outer ear: Not covered
• Hearing aids - over the ear: Not covered
Preventive dental
• Oral exam: $0 copay (limits apply)
• Cleaning: $0 copay (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s): $0 copay (limits apply)
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services: Not covered
• Restorative services: Not covered
• Endodontics: Not covered
• Periodontics: Not covered
• Extractions: Not covered
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
Vision
• Routine eye exam: $0 copay (limits apply)
• Other: Not covered
• Contact lenses: $0 copay (limits apply)
• Eyeglasses (frames and lenses): $0 copay (limits apply)
• Eyeglass frames: $0 copay (limits apply)
• Eyeglass lenses: $0 copay (limits apply)
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• $0 copay (limits apply)
Foot care (podiatry services)
• Foot exams and treatment: 0% or 20% coinsurance
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy: 0% or 20% coinsurance (authorization required)
• Other Part B drugs: 0% or 20% coinsurance (authorization required)

Fidelis Medicare Advantage Flex (HMO-POS) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. Primary Care Doctor Visit $0 Copay $0 Copay $0 Copay $. Please check with your Fidelis Care representative or visit fideliscare.org for information on products. This Fidelis Care plan does not offer additional coverage through the gap. H5599-009 Formulary or Drug Coverage. Fidelis Medicare $0 Premium (HMO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. The Fidelis Dual Advantage Flex (HMO D-SNP) (H5599 - 001) currently has 42,104 members. There are 270 members enrolled in this plan in Clinton, New York. Prescription Drug Coverage: Deductible, Cost-sharing, Formulary.

How Much Is Fidelis Care