Download FeelWell Medicare Advantage Prescription Drug (MA

FeelWell Medicare Advantage Prescription Drug (MA-PD) Plan
Covered Services Requirements
Covered Services
Requires Prior Authorization
Limitations
Abdominal Aortic Aneurism Screening- Diagnostic
Alcohol Misuse Screening Counseling
Ambulance (Emergency)
Ambulatory Surgical Centers
Annual Wellness Visit/Exam - Preventive
Bone Mass Measurement - Preventive
Breast Examination
Yes
No
No
Yes
No
No
No
Medical necessity
1 screening and 4 face-to-face annually
Breast Cancer Screening (Mammograms)Preventive
Cardiac Rehabilitation Services (includes exercise,
education, counselling) - Initial Course of
Treatment
Cardiovascular Disease Risk Reduction VisitPreventive
No
40 years or older every 12 months
Yes
2 one-hour sessions per week to
maximum of 36 weeks
No
Once every 12 months
Cardiovascular Disease Screening and TestingPreventive
Cervical and Vaginal Cancer Screening, Pelvic
Exam, Pap Test- Preventive
Chemotherapy
Chiropractic
No
Once every 5 years (60 months)
No
Once every 24 months or high-risk women
every 12 months
Colorectal Screening- Preventive
No
Defibrillator (implantable automatic)
No
Dental - Preventative dental services
Not Covered
Comprehensive Dental
Yes
Call HealthPlex for limitation information
888-468-2183
Depression Screening- Preventive
Diabetes Monitoring (Self-Management Training)
No
Yes
One every 12 months
Effective 1-1-2015 V.1
Yes
No
Every 12 months
Once every 24 months
40 years or older every 24 months
Covered for manual manipulation of the
spine to correct sublaxation
50 years or older: Fecal occult blood test
every 12 months; Flexible sigmoidoscopy
or (screening barium enema as an
alternative) every 48 months;
Colonoscopy (or screening barium enema
as an alternative) every 10 years. High risk
for colorectal cancer: Colonoscopy or
(screening Barium enema as an
alternative) every 24 months
FeelWell Medicare Advantage Prescription Drug (MA-PD) Plan
Covered Services Requirements
Covered Services
Requires Prior Authorization
Diabetes Screening- Preventive
No
Diabetes Services
Diabetes Supplies
Diabetic Therapeutic Shoes or Inserts
Yes
No
Yes
Diagnostic Testing- CT scan, MRI, PET scan, MRA
Durable Medical Equipment (DME)
Emergency Care
Eye Exams
Yes
Yes
No
No
Eye Wear
Yes
Hearing Exams
Hearing Aids
HIV Screening
No
Yes
No
Home Health
Home Infusion
Hospice Benefit
Immunizations : Influenza, Pneumococcal,
Hepatitis B vaccinations
Inpatient Hospital Care (including Substance Abuse
and Rehabilitation Services)
Inpatient Hospital Acute Care
Inpatient Mental Health Care
Kidney Disease Services
Kidney Disease Education
Yes
Yes
Not Covered
No
Medical Nutrition Therapy
Medical Social Services
No
Yes
Effective 1-1-2015 V.1
Limitations
2 every 12 months if there is a history of
HTN, High cholesterol/triglyceride level,
Obesity or hyperglycemia; or if 2 or more
apply: 65 years or older, obesity, family
history, or gestational diabetes
Refer to Medicare monthly limitations
One pair of custom-molded shoes
(including inserts) and two extra pairs of
inserts each calendar year
> $500
One routine eye exam and annual
glaucoma screening
One pair of eyeglasses with standard
frames (or one set of contact lenses)
following cataract surgery. Additionally, up
to $100 every year towards eye wear
$ 500 every 2 years
1 every 12 months for high risk people and
up to three screenings during a pregnancy
Up to 35 hours per week
Original Medicare benefit
Yes
Yes
Yes
Yes
Yes
6 education sessions for Stage IV, ESRD
every 12 months
Available if part of CHHA services/
Inpatient or SNF
FeelWell Medicare Advantage Prescription Drug (MA-PD) Plan
Covered Services Requirements
Covered Services
Requires Prior Authorization
Medicare Part B Prescription Drugs
Medicare Part D Prescription Drug Benefit as
Approved by CMS
Non-Emergency Transportation (Medicare
covered)
No
No
Obesity Screening and Therapy to Keep Weight
Down
No
Opioid Treatment Services - Substance Abuse
Other Health Care Hospital Professional Services
Over the Counter OTC benefit
Outpatient Blood Services
Outpatient Hospital Services
Outpatient Radiation Services
Outpatient - Medically Supervised WithdrawalSubstance Abuse
Outpatient Mental Health Care
Yes
Yes
No
Yes
Yes
Yes
Yes
Outpatient Rehabilitation (OT, PT, Speech)
Yes
Outpatient Substance Abuse
Outpatient Surgery
Palliative Care
Partial Hospitalization
PCP Office Visits
Podiatry
Preventive Services
Prostate Cancer Screening- Preventive
Yes
Yes
Not Covered
Yes
No
Yes
No
No
Prosthetics
Pulmonary Rehabilitation Services
Yes
Yes
Routine Physical Exam and Wellness Visit
No
Effective 1-1-2015 V.1
Yes
Limitations
Consult Formulary
10 round trips annually (roundtrip must be
same day door-to-door for medical
purposes and arranged in advance)
Authorization is performed by
transportation company
22 face to face sessions per year for IBT
(intensive behavioral therapy for obesity)
$ 75 per month allowance
First 3 pints of blood fee waived
Yes
Therapy cap limit: $1,940 for occupational
therapy and $1,940 for PT and ST
combined
Part of Medicare Hospice benefit
Men 50 years or older PSA test and a
digital rectal exam once every 12 months
2 one-hour sessions per day for up to 36
sessions spread over 36 weeks for
moderate to very severe COPD
Once every 12 months
FeelWell Medicare Advantage Prescription Drug (MA-PD) Plan
Covered Services Requirements
Covered Services
Requires Prior Authorization
Sexually Transmitted Infections (STIs) Screening
and Counseling - Preventive
No
Skilled Nursing Facility
Smoking and Tobacco Cessation -Initial
Yes
No
Specialist Office Visits
Substance Abuse Program
Urgent Care
"Welcome to Medicare" Preventive Visit
No
Yes
No
No
Effective 1-1-2015 V.1
Limitations
Once every 12 months. Two individual,
20–30 minute, face-to-face, high-intensity
behavioral counseling sessions each year
for sexually active adults at increased risk
for STIs
Two quit attempts counseling and 4 faceto-face visits within a 12 month period