CareWell Benefits*

CareWell (HMO I-SNP) H4922-004 
For Medicare beneficiaries residing in a contracted Skilled Nursing Facility
Monthly Plan Premium $0 or up to $42.40* (derived from Part D/LIS applicable)
Yearly Deductible/ MOOP B: $0 or $203*/C: $0*/MOOP: $7,550*   *2021 cost sharing will be updated when the 2022 numbers are released (Nov 2021)
Part D Yearly Deductible $0, $99 or $480*
Alternative therapy Offered in one (1) to two (2) group sessions covered each month, up to twenty (20) group sessions covered each year. Therapies may be done in person or online.
Chiropractor $0 or 20% of the cost*
Dental $0 Comprehensive Dental $1,350 limit per year
Diabetic Supplies $0 or 20% of the cost* Precision, OneTouch and FreeStyle preferred brands.  No prior auth. required.
Emergency Room/ Urgent Care $0 or 20% of the cost* (US + Territories Only)
Hearing $0 annual routine hearing exam; Our plan pays up to $1,500 every 3 years for Hearing Aids. 4 visits for fitting/evaluation for Hearing. Aids are covered within the first year after purchase of a Hearing Aid.
Hospital Inpatient/SNF $0 or Same as Original Medicare for 2022*
Lab/X-Ray/ Test & Procedures $0 or 20% of the cost* (prior auth. required for generic testing)
Outpatient Surgery $0 or 20% of the cost*
Part D Coverage $0, 15% or 25% coinsurance*.  Members with LIS or Medicaid: Generic copay: $0; $1.35; $3.95*     All other drugs copay: $0; $4.00; $9.85*
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
Vision $0 or 20% coinsurance* for routine eye exam; $150 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 2022 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.