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Ambetter from Fidelis Care Gold Wellness, Gold, NS, INN, Fidelis Care HBX Network, Dep25, Family Vision, Free Telemedicine Program, Family Dental
Health Insurance Plan Details (2025 Plan)
by Fidelis Care
Monthly Premium
HMO
$ubsidy
Gold
- Deductible
- $1,300 /yr
- Max Out-of-Pocket
- $5,700 /yr
Details
| Deductible (per individual) | $1,300 /yr |
| Deductible (per family) | $2,600 /yr |
| Max Out-of-Pocket (per individual) | $5,700 /yr |
| Max Out-of-Pocket (per family) | $11,400 /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 |
Out-of-Pocket Costs
| Preventive Care | No Charge |
| Primary Care Visit | $25 Copay |
| Specialist Visit | $40 Copay after deductible |
| Emergency Room | $150 Copay after deductible |
| Inpatient Facility | $1000 Copay per Stay after deductible |
| Inpatient Physician | $100 Copay after deductible |
| Generic Drugs | $10 Copay |
| Preferred Brand Drugs | $35 Copay |
| Non-preferred Brand Drugs | $70 Copay |
| Specialty Drugs | Not Applicable |
Plan Documents
| 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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