English - Fidelis Care

Fidelis Care
Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for
their Prescription Drug Costs
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs,
your monthly plan premium will be lower than what it would be if you did not get extra help
from Medicare. The amount of extra help you get will determine your total monthly plan
premium as a member of our Plan.
This table shows you what your monthly plan premium will be if you get extra help.
Your level of extra
help
100%
75%
50%
25%
Monthly Premium for
Fidelis Medicare
Advantage Flex
(HMO-POS)
$0
$9.90
$19.80
$29.80
Monthly Premium
for Fidelis Dual
Advantage
(HMO SNP)
$0
$9.90
$19.80
$29.80
Monthly Premium
for Fidelis Dual
Advantage Flex
(HMO SNP)
$0
$9.90
$19.80
$29.80
*This does not include any Medicare Part B premium you may have to pay.
Fidelis Medicare Advantage Flex, Fidelis Dual Advantage and Fidelis Dual Advantage Flex's
premium includes coverage for both medical services and prescription drug coverage.
If you aren’t getting extra help, you can see if you qualify by calling:
 1-800-Medicare of TTY/TDD users call 1-877-486-2048 (24 hours a day/7 days a week),
 Your State Medicaid Office, or
 The Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.
If you have any questions, please call Member Service at 1-800-247-1447, (TTY/TDD: 1-800695-8455) from October 1 to February 14, our office hours are 8:00 a.m. to 8:00 p.m. EST seven
days a week and from February 15 through September 30, our office hours are Monday through
Friday, 8:00 a.m. to 8:00 p.m. EST.
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.
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/coH3328_FC 15058 Accepted
insurance may change on January 1 of each year. You must continue to pay your Medicare Part
B premium.
This information is available for free in other languages. Please contact our Member Services
number at 1-800-247-1447 for additional information. (TTY users should call 1-800-695-8544).
Hours are 8:00 a.m. to 8:00 p.m. seven days a week from October 1st through February 14th and
Monday through Friday, 8:00 a.m. to 8:00 p.m. from February 15th through September 30th.
Member Services has free language interpreter services available for non-English speakers.
Esta información está disponible de forma gratuita en otros idiomas. Por favor comuníquese con
nuestro número de Servicios al Socio al 1-800-247-1447 para obtener información adicional. Los
usuarios con deficiencia auditiva (TTY) deberán llamar al 1-800-695-8544. El horario de
atención es de 8:00 a.m. a 8:00 p.m. los siete días de la semana desde el 1 de octubre hasta el 14
de febrero, y de lunes a viernes, de 8:00 a.m. hasta las 8:00 p.m. desde el 15 de febrero hasta el
30 de setiembre. Servicios al Socio también tiene servicios gratuitos de intérprete disponibles
para personas que no hablan inglés.
H3328_FC 15058 Accepted