AgeWell New York



Abdominal aortic aneurysm screeningNo One-Time Screening ultrasound for people at risk. Must have family history of AAA or male 65-75yrs who smoked at least 100 cigarettes in his lifetimeAcupunctureNoWe cover 6 acupuncture treatments/year when provided by certified network providersAir Ambulance ServicesNo(Prior Authorization is required for non-emergency air ambulance services)Covered emergency ambulance services include air ambulance and ground ambulance services, to the nearest appropriate facility that can provide care if they are furnished to a member whose medical condition is such that other means of transportation could endanger the person’s health or if authorized by the planNon-emergency transportation by air ambulance or ground ambulance is appropriate if it is documented that the member’s condition is such that other means of transportation could endanger the person’s health and that transportation by air ambulance is medically requiredGround Ambulance Services No(Prior Authorization is required for non-emergency ground ambulance services)Annual Routine Physical ExamNoAnnual Routine Physical Exam is limited to one each year.Annual Routine Physical Exam includes comprehensive physical examination and evaluation of status of chronic diseases. Doesn’t include lab tests, radiological diagnostic tests or non-radiological diagnostic tests or diagnostic tests. Additional cost share may apply to any lab or diagnostic testing performed during your visit.Annual wellness visitNo Once every 12 monthsBone mass measurementNoOnce every 24 months or more frequently if medically necessaryBreast cancer screening Screening mammogramNoOne baseline mammogram between ages 35-39One screening mammogram every 12 months for women 40 and olderClinical breast exams once every 24 monthsBreast cancerDiagnostic mammogramYesOnce a year or as many times as medically necessaryCardiac rehabilitation services(Includes exercise, education, counselling)- Initial course treatmentYesLimited to a maximum of 2, 1-hour sessions per day for up to 36 sessions with the option for an additional 36 sessions or an extended period of time if approved based on medical necessity./ Intensive cardiac rehab limited to 72, 1-hour sessions, up to 6 sessions per day, over a period of up to 18 weeksCardiovascular disease risk reduction visit (therapy for cardiovascular disease)NoOne visit per yearCardiovascular disease testingNoBlood tests (Lipid Panel) for the detection of cardiovascular disease (or abnormalities associated with an elevated risk of cardiovascular disease) once every 5 years (60 months)Cervical and vaginal cancer screeningPelvic ExamPap TestNoFor all women: Pap tests and pelvic exams once every 24 monthsAt high risk or have had an abnormal pap test and are of childbearing age: one Pap test every 12 monthsChiropractic servicesNoManual manipulation of the spine to correct subluxation (one or more of the bones of your spine move out of position)Colorectal cancer screening Colonoscopy (screening/preventive)YesFor people 50 and older: Flexible sigmoidoscopy (or screening barium enema as an alternative) every 48 months; One of the following every 12 months: Guaiac-based fecal occult blood test or Fecal immunochemical test; DNA based colorectal screening every 3 years;For people at high risk: Screening colonoscopy (or screening barium enema as an alternative) every 24 months;For people not at high risk: Screening colonoscopy every 10 years (120 months), but not within 48 months of a screening sigmoidoscopyColorectal cancerColonoscopy (surgical)YesDental servicesComprehensive servicesContact HealthPlex 1-800-468-9868 for coverage and authorizationComprehensive dental: Non-routine 1 every year; diagnostic services 1 every 6 months; restorative services 1 every year; Endodontics/periodontics/extractions 1 every year; prosthodontics, other oral/maxillofacial surgery 1 every yearDepression screeningNoOne screening for depression per yearDiabetes screeningNoBased on test results, we cover up to 2 diabetes screenings 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 diabetesDiabetes self-management trainingNoYou qualify for initial training and up to 2 hours of follow-up training each yearDiabetic services and suppliesNoSupplies to monitor your blood glucose. At high risk of diabetes, a family history of glaucoma, are African-American and 50 or older or are Hispanic American 65 or olderDiabetic therapeutic shoes and insertsYesOne pair per calendar year of therapeutic custom molded shoes (including inserts provided with such shoe).Two additional pairs of inserts, or one pair of depth shoes, and three pairs of inserts (not including the non-customized removable inserts provided with such shoes)Durable medical equipment and related suppliesYesCovered items include, but are not limited to: wheelchairs, crutches, hospital bed, IV infusion pump, oxygen equipment, nebulizer, and walker. Please refer to Medicare limitationsEmergency care (US + Territories Only)NoMedical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting Worse.If you are admitted to the hospital within 24 hours for the same condition, you do not pay the cost share.Fitness ProgramRegistration is required contact Silver Sneakers 1-888-423-4632Hearing services by a physician, audiologist, or other qualified providerNo (Contact EPIC Hearing 1-877-606-3742 for coverage)Diagnostic hearing and balance evaluations performed by your provider to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider1 Routine Hearing Exam per yearHearing aidsYes (Contact EPIC Hearing 1-877-606-3742 for coverage)We cover $1,000 towards the purchase of hearing aids once every 2 yearsIncludes fitting and evaluation for hearing aids.HIV screeningNoIncreased risk: one screening exam every 12 monthsWomen who are pregnant: 3 screening exams during pregnancyHome health agency careYesMust total fewer than 8 hours per day and 35 hours per weekHospice careNot CoveredOriginal Medicare benefitImmunizationsInfluenzaPneumococcalHepatitis BNoFlu shots once a year in the fall or winterPneumonia vaccines, Hepatitis B and other vaccines if you are at risk and they meet Medicare Part B coverage rulesInpatient hospital careYesBenefit period begins the day you are admitted as an inpatient in the hospital and ends when you haven’t received any inpatient care for 60 consecutive daysInpatient mental health careYesUp to 90 days of medically necessary hospitalization and 40 additional days in a Psychiatric hospitalMedical nutrition therapyNoThis benefit is for people with diabetes, renal (kidney) disease (but not on dialysis), or after a kidney transplant when ordered by your doctor. 3 hours of one-on-one counseling services during your first year, 2 hours each year after thatMedicare Diabetes Prevention Program (MDPP)NoMDPP services will be covered for eligible Medicare beneficiariesMedicare Part B prescription drugsYesStep Therapy may apply to certain drugs.Medicare Part D prescription DrugsYesConsult Formulary for PA requirements on certain drugs EnvisionRx 1-800-361-4542Depending on your level of Medicaid/LISObesity screening and therapy to promote sustained weight lossNoIf you have body mass index 30 or moreOutpatient diagnostic tests and therapeutic services and supplies (Part 1)Preventive Diagnostic procedures and testsX-RaysLab servicesDiagnostic procedures and tests such as:-Echocardiogram-EKG-Sonogram-UltrasoundNo (Prior Authorization is needed for tests that require contrasts or Anesthesia)Outpatient diagnostic tests and therapeutic services and supplies (Part 2)Surgical and medical suppliesBlood ServicesTherapeutic radiological services Diagnostic radiological services (CT, MRI, PET scan, MRA, etc)YesOutpatient hospital servicesYes - for tests that require Anesthesia(Prior Authorization is not required for tests such as Sonogram/Ultrasound, Electrocardiogram, X-Ray and Lab)We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injuryCovered services include, but are not limited to: Services in an emergency department or outpatient clinic, such as observation services or outpatient surgery Laboratory and diagnostic tests billed by the hospital Mental health care, including care in a partial-hospitalization program, if a doctor certifies that inpatient treatment would be required without it X-rays and other radiology services billed by the hospital Medical supplies such as splints and casts Certain screenings and preventive services Certain drugs and biologicals that you can’t give yourselfOutpatient mental health careYes Cover individual or group outpatient mental health careOutpatient rehabilitation services Occupational therapyPhysical therapySpeech-language pathology (Speech therapy)YesIn 2018 Therapy Cap Limits for PT and SLP combined is $2,010 and for OT is $2,010Outpatient substance abuse servicesYesCover individual and group outpatient substance abuse servicesOutpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centersYesOver-The-Counter benefitNo$80 per month for OTCPartial hospitalization servicesYesPhysician/Practitioner services, including doctor’s office PCPSpecialistNo (Prior Authorization is needed for tests that require Contrasts or Anesthesia)Annual Routine Physical Exam includes comprehensive physical examination and evaluation of status of chronic diseases. Doesn’t include lab tests, radiological diagnostic tests or non-radiological diagnostic tests or diagnostic tests. Additional cost share may apply to any lab or diagnostic testing performed during your visit.Podiatry servicesNail debridement and clippingNoNail debridement and clippingMust meet Medicare criteria for Podiatry servicesProstate cancer screening examsNoFor men age 50 and older once every 12 months: digital rectal exam or prostate specific antigen testProsthetic devices and related suppliesYesPulmonary rehabilitation servicesYesLimited to up to 36 sessions, no more than two sessions per dayScreening and counseling to reduce alcohol misuseNoOne alcohol misuse screening for adults who misuse alcohol but aren’t alcohol dependentIf you screen positive for alcohol misuse, you get up to 4 face-to-face counseling sessions per yearScreening for lung cancer with low dose computed tomographyNoCovered once every 12 months for people 55-77 years who have a history of tobacco smokingScreening for sexually transmitted infections (STIs) and counseling to prevent STIsNoCover tests once every 12 months or at certain times during pregnancyCover up to 2 individual 20 to 30 minutes face-to-face counseling sessions each yearServices to treat Kidney disease and conditionsKidney disease educationDialysisYesSkilled nursing facility (SNF) careYesCovered for 100 days in a SNF during each benefit period.Smoking and tobacco use cessation (counseling to stop smoking or tobacco use)NoIf you use tobacco but do not have signs of tobacco related disease we cover two counseling sessions within a 12 month period If you use tobacco and have been diagnosed with a tobacco related disease we cover two counseling sessions with 12 month period, however, there is a cost share(Each counseling attempt includes up to 4 face-to-face visits)Supervised Exercise Therapy (SET)YesUp to 36 sessions over a 12-week period are covered if the SET program requirements are met. SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. Telemonitoring ServicesYes (referral may also be required)Model of care intended to reduce avoidable hospital admissions for members living with chronic conditions and transitioning from home health services to community with no formal support. Telemonitoring is provided through structured electronic contact between members and health care providers (with or without home visits) and includes reporting of symptoms and physiological data to physicians. The tele monitoring benefit does not include blood glucose monitors.If a member calls for this benefit: “This benefit is offered to qualified members based on certain criteria; if you wish to know if you qualify, let me put you in contact with one of our Wellness Coaches to determine if the service is appropriate for you” (number will be posted on intranet). You can also call the Navigator line 718.696.0203 to be transferred. Thank you for your call”.TransportationNot coveredUrgently needed services (US + Territories Only)NoVision CareGlaucoma screeningNo (Contact National Vision Associates 1-844-344-1250 for coverage and authorization)High risk of Glaucoma 1 screening per yearFor people with diabetes one screening for diabetic retinopathy per yearOne pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery that implants an intraocular lens.Eye WearYes (Contact National Vision Associates 1-844-344-1250 for coverage and authorization)One pair of eyeglasses or one set of contact lenses after cataract surgery with an intraocular lens“Welcome to Medicare” Preventive visitNoOne time visit only within the first 12 months you have Medicare Part BMedicare-covered EKG following Welcome Visit Preventive Services at no additional cost. ................
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