Fidelis Silver NY

Plan Information
Company Fidelis Care
State NY
Metal Tier Silver
Plan Type

Cost Sharing Benefits

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.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $2,000 $0
Deductible (Family) $4,000 $0
Coinsurance $0 $0
Out of Pocket Maximum (Individual) $5,500 $0
Out of Pocket Maximum (Family) $11,000 $0
Services In Network Out of Network
Primary Care Visit $30 copay $0
Specialist Visit $50 copay $0
In Patient Hospital Services $1,500 copay $0
Emergency Room Services $150 copay $150 copay
Mental / Behavioral Health $30 copay $0
Imaging (CT/PET Scans, MRIs) $50 copay $0
Rehabilitative Speech Therapy $30 copay $0
Rehabilitative Occupational & Physical Therapy $30 copay $0
Preventative Care $0 $0
Laboratory Outpatient and Professional Services $50 copay $0
X-ray and Diagnostic Imaging $50 copay $0
Outpatient Facility $100 copay $0
Outpatient Surgery $100 copay $0
Prescription Drugs In Network Out of Network
Generic Rx $10 copay
Preferred Brand Rx $35 copay
Non Preferred Brand Rx $70 copay
Specialty Drugs 70

Other Plans

Other plans that are available in the state.

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