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 .