CareWell Benefits*

For Medicare beneficiaries residing in a contracted Skilled Nursing Facility
Monthly Plan Premium $0 or up to $38.90* (derived from Part D/LIS applicable)
Maximum out-of-pocket (MOOP) $7,550
Part D Yearly Deductible $0 or $104 (partial subsidy) or $505 (retiree drug subsidy cost threshold)**
Alternative therapy  $0 copay for each therapy: Offered in one to two group sessions covered each month, up to twenty group sessions covered each year. Therapies may be done in person or online.

Alternative therapies may include:
(a) Dance Movement Therapy, Music Therapy, Meditation, Chair Yoga or Tai -Chi.
(b) Virtual Reality sessions

Chiropractor $0 or 20% of the cost*
Dental $0 Comprehensive Dental $1,350 limit per year.
Diabetic  $0 copay Precision, OneTouch and FreeStyle preferred brands. No prior authorization required. 20% coinsurance, diabetic shoes/inserts (if the member has Medicaid, they will cover Medicaid cost-share).
Emergency Room/ Urgent Care $0 or 20% of the cost* (up to a maximum of $95 for each emergency room visit and up to a maximum of $60 for urgent care visits) (US + Territories Only)
Hearing $0 annual routine hearing exam; Our plan pays up to $1,500 every 2 years for Hearing Aids. 4 visits for fitting/evaluation for Hearing. Aids are covered within the two years after the purchase of a Hearing Aid.
Hospital Inpatient Stay $0 or same as Original Medicare*
Lab/ X-Ray/ Test & Procedures $0 or 20% of the cost*
Outpatient Surgery $0 or 20% of the cost*
Part D Coverage $0, 15% or 25% coinsurance*.  Members with LIS or Medicaid: Generic copay: $0; $1.45; $4.15* or 15%. All other drugs copay: $0; $4.30; $10.35* or 15%.
Primary Care Physician $0 or 20% of the cost* Telehealth or in person.
Screening & Immunization $0 copay
Specialist $0 or 20% of the cost* No referral required. Telehealth or in person.
Vision $0 for two routine eye exams per year; $500 each year for eyeglasses. Prior Authorization is required for eyeglasses.

For more information about covered services associated and cost-sharing (e.g., co-payments, co-insurance and deductibles) including any conditions and limitations please refer to the 2023 CareWell Summary of Benefitsopens PDF file .

**Licensed Master Social Worker and a Nurse Practitioner are assigned to members

*Depending on your Medicaid eligibility, you may pay a lower cost share amount.
This plan uses a formulary. Limitations may apply.