SHB_p010

SC11122015

10 The Courier sun • NOVEMBER 12, 2015 FOR BREAKING NEWS VISIT www.qns.com Fidelis Care’s Medicare Advantage Plans for 2016 The Benefits You Care About... For 2016, here are highlights of our in-network(2) benefits compared to Original Medicare. Benefit Original Medicare(3) Fidelis Medicare Advantage Flex (HMO-POS) *Fidelis Medicare $0 Premium (HMO) Monthly Part B Premium (1) $104.90 $39.70 $0 Flex Benefit None $400 per year None Part B Deductible $147 None None PCP Copay 20% $0 $15 Specialist Copay 20% $15 $40 Outpatient Surgery in a 20% $300 $300 Hospital Outpatient Surgery in an Ambulatory Surgical Center 20% $300 $300 Lab Tests $0 or 20% 20% 20% X-rays 20% $10 $10 Preventive Services $0 $0 $0 MRIs, CT Scans, PET 20% 20% 20% Scans Inpatient Copay $1,216 $300 per day for days 1-5, per admission $300 per day for days 1-5, per admission Part D Prescription Drug Coverage No Yes, with $0 copay for preferred generics $250 deductible Yes, with $0 copay for preferred generics Preventive Dental None Yes Yes Call 1-800-860-8707 (TTY: 1-800-558-1125) 8 AM to 8 PM seven days a week from October 1 to February 14, and Monday through Friday, 8 AM to 8 PM from February 15 through September 30 Enroll anytime at fideliscare.org 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, premium and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. 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. Fidelis Care is an HMO plan with a Medicare contract. Enrollment in Fidelis Care depends on contract renewal. H3328_FC 15107 Accepted


SC11122015
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