Fidelis Care Gold for Children Child Only ST INN Pediatric Dental

Individual Health Insurance (Obamacare)

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Benefits & Coverage

Plan Name
Fidelis Care Gold for Children Child Only ST INN Pediatric Dental
Plan Year
2016
Insurance Type
Individual Health Insurance (Obamacare)
Insurance Provider
Metal Level
Gold
Out-of-Pocket Maximum
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness
$25 Copay after deductible
Specialist Visit
$40 Copay after deductible
Laboratory Outpatient and Professional Services
$40 Copay after deductible
X-rays and Diagnostic Imaging
$40 Copay after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans
$40 Copay after deductible
Deductible - Family
$1200 per group
Out-of-Pocket Maximum - Family
$8000 per group

Prescription drug coverage

Generic Drugs
$10 Copay
Preferred Brand Drugs
$35 Copay
Non-Preferred Brand Drugs
$70 Copay
Specialty Drugs
Not Applicable

Access to doctors and hospitals

Provider directory URL
http://www.fideliscare.org/apps/providersearch/
Does this plan have access to a national provider network?
No
Is a referral required to see a Specialist?
Not Covered
Does this plan cover services outside plan service area?
Not Covered
Does this plan cover services outside the country?
Not Covered

Hospital services

Emergency Room Services
$150 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
$1000 Copay per Stay after deductible
Inpatient Physician and Surgical Services
$100 Copay after deductible
Emergency Transportation or Ambulance Service
$150 Copay after deductible

Maternity

Prenatal and Postnatal Care
Not Applicable
Delivery and all inpatient services for maternity care
$1100 Copay after deductible

Mental Health

Mental/Behavioral Health Outpatient Services
$25 Copay after deductible
Mental/Behavioral Health Inpatient Services
$1000 Copay per Stay after deductible
Substance use disorder outpatient services
$25 Copay after deductible
Substance use disorder inpatient services
$1000 Copay per Stay after deductible

Medical Management Programs

Does this plan offer a wellness program?
Not Covered

Vision Coverage

Routine Eye Exam for Children
Included
Eye Glasses for Children
Included
Routine Eye Exam for Adults
Not Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental Care
Included
Child Dental Coverage - Basic Dental Care
Included
Child Dental Coverage - Orthodontia
Included
Child Dental Coverage - Major Dental Care
Included

Adult Dental Coverage

Adult Dental Coverage - Routine Dental Care
Not Covered
Adult Dental Coverage - Basic Dental Care
Not Covered
Adult Dental Coverage - Orthodontia
Not Covered
Adult Dental Coverage - Major Dental Care
Not Covered

Exclusions and Limitations

More Included Benefits
Other Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Bariatric Surgery
Hearing Aids
Infertility Treatment
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Chiropractic Care
Inpatient Rehabilitation Services
Cochlear Implants
Diabetes Care Management
Inherited Metabolic Disorder - PKU
Second Opinion
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Autism Spectrum Disorders
Breast Reconstructive Surgery
Cardiac Rehabilitation
Experimental or Investigational Services
Post-Mastectomy Care
Prostate Cancer Screening
Assistive Communication Devices
Autologous Blood Banking
Diabetic Equipment & Supplies
Gym Membership Reimbursement
Medical Supplies
Observation Stay
Preadmission Testing
Design
Family Planning Services
Sterilization Procedures for Men
Anesthesia Services
More Limited Benefits
Skilled Nursing Facility
Home Health Care Services
Hospice Services
Dental Check-Up for Children
Contact Lenses for Children
More Excluded Benefits
Acupuncture
Cosmetic Surgery
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Routine Foot Care
Non-Emergency Care When Traveling Outside the U.S.
Abortion for Which Public Funding is Prohibited

What To Know

  • This is an ACA (Obamacare) compliant health plan.

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