Reminder: Ambetter From Fidelis Care and Essential Plan - Diabetes and Maternity Services Cost-Share Changes as of January 1, 2025
2025/3/10
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Posted by Provider Relations
Fidelis Care would like to remind our providers of plan changes effective January 1, 2025, for Ambetter From Fidelis Care and Essential Plans. In order for members to obtain the in-network cost share benefit for Diabetes and Maternity Services, providers should follow the below guidance when sending prescriptions to pharmacies for applicable members.
As a reminder, members who become pregnant are required to report their pregnancy to the New York State of Health Marketplace Phone Number below to be eligible for the Pregnancy Cost-Share Waiver.
- New York State of Health Marketplace Phone: (855) 355-5777 TTY: (800) 662-1220.
| 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. |
If you have any questions, please contact your Fidelis Care Provider Engagement Account Manager. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist.
Thank you for partnering with us to support the health and wellness of our members!