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 .