LiveWell (HMO) Benefits
| LiveWell (HMO) Benefits | |
|---|---|
| Monthly Plan Premium | $0 |
| Maximum out-of-pocket (MOOP) | $7,550 |
| Prescription Coverage (Part D) / Part D Deductible | $0 deductible Tiers 1 & 2/$350 deductible Tiers 3 & above |
| PCP/ Specialist/ Telehealth | $10 copay PCP/$25 copay Specialist, includes telehealth |
| Acupuncture | $10 copay per visit, 15 additional visits per year to the Medicare-covered acupuncture |
| Ambulance | $260 copay ground (waived if Admitted to Hospital)/Air Ambulance Services 20% (not waived) |
| Chiropractor | $20 copay |
| Dental – Optional Supplemental | $15 monthly premium for preventive and comprehensive services (No Cap on services) |
| Diabetic | $0 copay OneTouch, Precision and FreeStyle preferred brands. No prior authorization required |
| Emergency Room | $90 copay (US + Territories Only) waived if admitted to hospital within 24 hours |
| Hearing | $0 copay hearing exam; $2,000 for Hearing Aids every 2 years |
| Hospital | $1,000 annual deductible for Inpatient Hospital, Surgery, or Dialysis |
| Hospital Copays | $155 for days 1 – 5, $0 for days 6 – 90 |
| Lab/ X-Ray | $10 copay at lab or doctor’s office, $30 copay hospital/ $30 copay x-ray |
| Outpatient Surgery | $475 copay |
| Physical Therapy | $35 copay, no referral required (Prior authorization required) |
| Screening & Immunization | $0 copay |
| Skilled Nursing Facility (SNF) | $0 copay days 1-20; $188 copay per day for days 21-100; no 3-day hospital stay required |
| Telemonitoring Services | $0 copay |
| Test & Procedures / MRI & CT Scan | Diagnostic Radiology (MRI, CT, etc.) 20% coinsurance; $215 maximum copay, freestanding; $300 max copay outpatient. |
| Urgent Care | $40 copay (US + Territories Only) waived if admitted to hospital within 24 hours |
| Vision | $0 copay routine eye exam, 1 per year/ $0 copay Medicare-covered eye exam, 1 per year, all other follow-up services at $40 copay |
| Vision – Optional Supplemental | $5 monthly premium/ $275 total toward eyeglasses or contact lenses |
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 LiveWell Summary of Benefitsopens PDF file .