|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:
|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.