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