Fidelis Silver (New York)

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Company Fidelis Care
Plan Year 2014
State New York
Metal Tier Silver
Plan Type
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Cost Sharing Benefits (In Network)

These details are for the standard Silver plan. For reduced Cost Sharing versions scroll down below

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductible (Individual) $2,000
Deductible (Family) $4,000
Coinsurance $0
Out of Pocket Maximum (Individual) $5,500
Out of Pocket Maximum (Family) $11,000

Doctors Visits

Primary Care Visit $30 copay
Specialist Visit $50 copay
In Patient Hospital Services $1,500 copay
Emergency Room Services $150 copay

Tests and Imaging

Imaging (CT/PET Scans, MRIs) $50 copay
Laboratory Outpatient and Professional Services $50 copay
X-ray and Diagnostic Imaging $50 copay


Mental / Behavioral Health $30 copay
Rehabilitative Speech Therapy $30 copay
Rehabilitative Occupational & Physical Therapy $30 copay
Outpatient Facility $100 copay
Outpatient Surgery $100 copay

Prescription Drugs

Generic Rx $10 copay
Preferred Brand Rx $35 copay
Non Preferred Brand Rx $70 copay
Specialty Drugs 70

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