Ambetter from Fidelis Care Silver One, Silver, NS, INN, Fidelis Care HBX Network, Dep29, Free Telemedicine Program, Family Dental

Health Insurance Plan Details (2025 Plan)

SBC doc

doctor lookup

HMO

Silver

Deductible (per individual)	$4,500 /yr
Deductible (per family)	$9,000 /yr
Max Out-of-Pocket (per individual)	$8,000 /yr
Max Out-of-Pocket (per family)	$16,000 /yr
Drug Deductible (per individual)
Drug Deductible (per family)
Drug Max Out-of-Pocket (per individual)
Drug Max Out-of-Pocket (per family)
Plan Type	HMO
Includes Child Dental?	Yes
Includes Adult Dental?	Yes

Medical Services
Preventive Care	No Charge
Primary Care Visit	$35 Copay
Specialist Visit	$60 Copay
Emergency Room	40.00% Coinsurance after deductible
Inpatient Facility	40.00% Coinsurance after deductible
Inpatient Physician	40.00% Coinsurance after deductible

Drug Costs
Generic Drugs	$20 Copay
Preferred Brand Drugs	$55 Copay
Non-preferred Brand Drugs	45.00% Coinsurance after deductible
Specialty Drugs	Not Applicable

Summary of Benefits and Coverage	SBC doc
Provider Directory	Doctor lookup
Drug Formulary List	n/a

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible

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