FeelWell (HMO D-SNP) Benefits*

FeelWell (HMO D-SNP) H4922-003
For Beneficiaries with both Medicare and Full Medicaid or QMB Only
Monthly Plan Premium $0* copay
Part B/C/D Yearly Deductible $0* copay / Part D MOOP $7,050
MOOP $0 or $3,450*
PCP / SPEC in person or by Telehealth $0* copay / $0* copay, No referral required
Acupuncture $0 copay per visit, 30 additional visits per year to the Medicare-covered acupuncture
Chiropractor $0* copay
Dental $0 copay for Preventive and Comprehensive Dental ($2,000 per year for Comprehensive services)
Diabetic Supplies $0* copay Precision, OneTouch and FreeStyle preferred brands. No prior authorization required.
Emergency Room/ Urgent Care $0* copay (US + Territories Only)
Hearing $0 annual hearing exam; $1,000 for Hearing Aids every 2 years, 4 visits for fitting/ evaluation for Hearing. Aids are covered within the first year after purchase of a Hearing Aid.
Hospital Inpatient/SNF $0* copay
Lab/X-Ray/ Test & Procedures $0* copay
OTC $125 per month
Outpatient Surgery $0* copay
Physical Therapy $0* copay
Screening & Immunization $0 copay
Telemonitoring Services $0 copay
Transportation $0 for 8 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; $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 FeelWell Summary of Benefitsopens PDF file .

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