LiveWell (HMO) Benefits
| LiveWell (HMO) H4922-011 (MAPD) | |
|---|---|
| Monthly Plan Premium | $42.40 (derived from Part D/LIS applicable) |
| Yearly Deductible/ MOOP | C: $1,750 (IP Hospital; OP Surgery; Dialysis)/ B: $0 / MOOP $7,550 |
| Part D yearly Deductible | $350: Tiers 1 & 2 are excluded from the Deductible |
| PCP / SPEC in person or by Telehealth | $10 copay ($40 copay for Physician Specialist Services, Outpatient Mental Health and Psychiatric Services, Outpatient Substance Abuse Services) |
| 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 | $16 monthly premium for preventive and comprehensive services (No Cap on services) |
| Diabetic Supplies | $0 copay Precision, OneTouch and FreeStyle preferred brands. No prior authorization required. |
| Emergency Room | $90 copay (US + Territories Only) waived if admitted to hospital within 24hrs |
| Hearing | $0 copay hearing exam; $1,000 for Hearing Aids every 2 years. Aids are covered within the first year after purchase of a Hearing Aid. |
| Hospital Inpatient | $155 copay for days 1 – 5, $0 for days 6 – 90 |
| Lab/ X-Ray | $10 copay at lab or doctor office, $40 copay hospital/ $30 copay X-Ray |
| Outpatient Surgery | $475 copay |
| Physical Therapy | $35 copay, No referral required (Prior authorization required) |
| Screening & Immunization | $0 copay |
| 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 | $20 copay at doctor office or free-standing clinics/ $30 copay for outpatient hospital / $215 copay |
| Urgent Care | $40 copay (US + Territories Only) waived if admitted to hospital within 24hrs |
| 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 | $8.30 monthly premium/ $275 total toward 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 LiveWell Summary of Benefitsopens PDF file .