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.