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Ambetter From Fidelis Care (Metal-Level Products)

Diabetes Services

Effective January 1, 2025, most Fidelis Marketplace members will not be responsible for the in-network cost share for some services related to the diagnosis and management of diabetes, inclusive of diabetic medications and diabetic supplies covered under the Pharmacy Benefit. Cost sharing will be waived for the following services for members whose primary diagnosis is diabetes.

• Primary Care Visits
• Dilated Retinal Exam (once per year)
• Diabetic Foot Exam (once per year)
• Nutritional Counseling

REMINDER: For cost sharing to be waived on Pharmacy Benefit claims, members’ diabetes prescriptions sent to their pharmacy of choice must include an ICD-10 diagnosis for diabetes.

Maternity Services

Effective January 1, 2025, there will be no cost-sharing obligations for most members who become pregnant for most services. Cost sharing will be waived from the onset of pregnancy to the 12-month postpartum period following delivery, inclusive of medications and supplies covered under the Pharmacy Benefit.

Cost sharing will apply to the following services.

• Ambulance Services
• All Inpatient Services (hospital, rehabilitation, mental health/substance use disorder, hospice)
• Emergency Care in a Hospital
• Physician, Nurse Practitioner and Midwife Services for Delivery
• Inpatient Hospital and Birthing Center Services for Delivery
• Pediatric Vision and Dental

To ensure cost-shares are appropriately waived on Pharmacy Benefit claims for all pregnant members, it is highly recommended to include an ICD-10 diagnosis for pregnancy OR post-partum care on pregnant members’ prescriptions sent to their pharmacy of choice.

Essential Plans

Diabetes Services

Effective January 1, 2025, most Fidelis Marketplace members will not be responsible for the in-network cost share for some services related to the diagnosis and management of diabetes, inclusive of diabetic medications and diabetic supplies covered under the Pharmacy Benefit. Cost sharing will be waived for the following services for members whose primary diagnosis is diabetes.

• Primary Care Visits
• 1 Dilated Retinal Exam per year
• Diabetic Foot Exam (once per year)
• Nutritional Counseling

REMINDER: For cost sharing to be waived on Pharmacy Benefit claims, members’ diabetes prescriptions sent to their pharmacy of choice must include an ICD-10 diagnosis for diabetes.