FeelWell (HMO D-SNP) Benefits*

FeelWell Benefits
Monthly Plan Premium $0* copay
Yearly Deductible $0*
Maximum out-of-pocket (MOOP) $0 or $3,650*
PCP/ Specialist/ Telehealth $0* copay, no referral required
Acupuncture $0 copay per visit, 30 additional visits per year
Chiropractor $0* copay
Dental $0 copay, Up to $3,000 maximum per year Preventive/Comprehensive Services
Diabetic $0* copay
OneTouch, Precision Xtra and FreeStyle brands. Plus $150 diabetic healthy food card per month
Emergency Room/ Urgent Care $0* copay (U.S. + Territories) and up to $50,000 for emergency and urgent care outside the U.S.
Hearing $0 annual hearing exam; $1,500 for Hearing Aids every 2 years, 4 visits for fitting/ evaluation for Hearing Aids are covered within the first year after purchasing a Hearing Aid
Hospital Inpatient/ SNF $0* copay
Lab/ X-Ray/ Test & Procedures $0* copay
Over-the-Counter (OTC) $225 per month
Outpatient Surgery $0* copay
Physical Therapy $0* copay
Screening & Immunization $0 copay
Telemonitoring Services $0 copay
Transportation $0 for 24 one-way trips post-hospitalization or as approved by the plan. Taxi, rideshare services, bus/subway, van, medical transport
Vision $0 copay for Routine Eye Exam per year; $200 for eyewear per year
Post Discharge Meals Two meals per day for two weeks after hospital discharge provided by FarmboxRx at $0 copay offered up to twice per enrollment year

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 FeelWell Summary of Benefitsopens PDF file .

* Depending on your Medicaid eligibility.
This plan uses a formulary. Limitations may apply.