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|
|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.