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.