Name / Nombre

JOHN L SMITH

Medicare Number / Número de Medicare

1XX0-XX0-XX00

Entitled to / Con derecho a

Medicare Card NEW

MEDICARE HEALTH INSURANCE

Coverage starts / Cobertura empieza

Medicaid / Common Benefit Identification Card( CBIC) NEW

OR

SAMPLE

OR

You may be eligible for additional money-saving benefits including:

• Monthly Over-the-Counter( OTC) Card( to pay for items like OTC medications, toothpaste, incontinence supplies, and more)

• Transportation

• Flexible Spending Dollars

• Dental

• Care Management support

• Top-quality doctors and hospitals

• Discounts for hearing devices *

For a complete listing of plans available in your service area, contact the plan. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and / or copayments / coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Out-of-network services may require more out-of-pocket expense than in-network services. Benefit restrictions apply. Fidelis Legacy Plan is an HMO plan with a Medicare contract. Enrollment in Fidelis Legacy Plan depends on contract renewal. * Fidelis Legacy Plan partners with TruHearing for discounted purchases of hearing devices.

@ fideliscare www. fideliscare. org

H3328 _ FC 17123 Accepted