FeelWell (HMO D-SNP) Benefits*
|Monthly Plan Premium||$0* copay|
|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|
|Dental||$0 copay, Up to $3,000 maximum per year Preventive/Comprehensive Services|
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.