AgeWell New York – Feel Well, Live Well with …



|Abdominal aortic aneurysm screening |No |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 lifetime |

|Acupuncture |No |Covered services include 10 acupuncture treatments per year when provided by certified network providers |

|Ambulance Services - Air |No | |

| | |Covered emergency ambulance services include air ambulance and ground ambulance services, to the nearest appropriate facility that can|

| |(Prior Authorization is |provide care if they are furnished to a member whose medical condition is such that other means of transportation could endanger the |

| |required for non-emergency air |person’s health or if authorized by the plan |

| |ambulance services) | |

| | |Non-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 |

| | |required |

|Ambulance services - Ground |No | |

| | | |

| |(Prior Authorization is | |

| |required for non-emergency | |

| |ground ambulance services) | |

|Annual Routine Physical Exam |No |Annual 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 visit |No |Once every 12 months |

|Bone mass measurement |No |Once every 24 months or more frequently if medically necessary |

|Breast cancer screening |No |One baseline mammogram between ages 35-39/ One screening mammogram every 12 months for women 40 and older/ Clinical breast exams once |

|Screening mammogram | |every 24 months |

|Breast cancer |Yes |Once a year or as many times as medically necessary |

|Diagnostic mammogram | | |

|Cardiac rehabilitation services |Yes |Limited 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|

|(Includes exercise, education, counselling)- Initial | |period of time if approved based on medical necessity/ Intensive cardiac rehab limited to 72, 1-hour sessions, up to 6 sessions per |

|course treatment | |day, over a period of up to 18 weeks |

|Cardiovascular disease risk reduction visit (therapy for |No |One visit per year |

|cardiovascular disease) | | |

|Cardiovascular disease testing |No |Tests for detection once every 5 years (60 months) |

|Cervical and vaginal cancer screening |No |For all women: Pap tests and pelvic exams once every 24 months |

|Pelvic Exam | |At high risk or have had an abnormal pap test and are of childbearing age and have had an abnormal Pap test within the past 3 years: |

|Pap Test | |one Pap test every 12 months |

|Chiropractic services |No |Manual manipulation of the spine to correct subluxation (one or more of the bones of your spine move out of position) |

|Colorectal cancer screening | |For people 50 and older: Flexible sigmoidoscopy (or screening barium enema as an alternative) every 48 months; |

|Colonoscopy (screening/preventive) |Yes |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 sigmoidoscopy |

| | | |

| | |IMPORTANT: If a screening colonoscopy or screening flexible sigmoidoscopy results in the biopsy or removal of a lesion or growth |

| | |during the same visit, the procedure is considered diagnostic and cost-share applies |

|Colorectal cancer | | |

|Colonoscopy (diagnostic/surgical) |Yes | |

| | | |

| | | |

|Dental services (Optional Supplemental Benefit) |Contact HealthPlex |Optional Dental Benefit: Diagnostic and restorative services, oral exams, cleaning, fluoride treatment, dental x-rays, endodontics, |

|Preventive services |1-800-468-9868 for coverage and|periodontics, extractions, prosthodontics, oral surgery, and other services. |

|Comprehensive services |authorization |Preventive dental: Oral exams one every 6 months; Prophylaxis (cleaning) one every 6 months; Fluoride treatment one every 6 months; |

| | |Dental x-ray(s) one every 6 months |

| | |Comprehensive dental: Diagnostic services one every 6 months, Restorative Services, endodontics/periodontics extractions, |

| | |prosthodontics, oral/maxillofacial surgery |

|Depression screening |No |One screening for depression per year |

|Diabetes screening |No |Based 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 diabetes |

|Diabetes self-management training |No |You qualify for initial training and up to 2 hours of follow-up training each year |

|Diabetic services and supplies |No |Supplies to monitor your blood glucose |

|Diabetic therapeutic shoes and inserts |Yes |One 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 supplies |Yes |Covered items include, but are not limited to: wheelchairs, crutches, hospital bed, IV infusion pump, oxygen equipment, nebulizer, and|

| | |walker. Please refer to Medicare limitations |

|Emergency care (US + Territories Only) |No |Medical 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 copay. |

|Fitness Program |Registration is required | |

| |contact Silver Sneakers | |

| |1-888-423-4632 | |

|Hearing services |No |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 provider |

| |(Contact EPIC Hearing |1 Routine Hearing Exam per year |

| |1-877-606-3742 for coverage) | |

| | | |

|Hearing aids |Yes |We cover $1,000 towards the purchase of hearing aids once every 2 years |

| | |Includes fitting and evaluation for hearing aids. |

| |(Contact EPIC Hearing | |

| |1-877-606-3742 for coverage) | |

|HIV screening |No |Increased risk: one screening exam every 12 months or for women who are pregnant: up to 3 screening exams during pregnancy |

|Home health agency care |Yes |Services must total fewer than 8 hours per day & 35 hours per week; Medicare requirements for skilled care apply. |

|Hospice care |Covered under Original Medicare|Medicare-certified hospice program is covered by Original Medicare. You are eligible for the hospice benefit when your doctor and the |

| | |hospice medical director have given you a terminal prognosis certifying that you’re terminally ill and have 6 months or less to live |

| | |if your illness runs its normal course ( For more information see EOC and ) |

|Immunizations |No |Flu shots once a year in the fall or winter with additional flu shots, if medically necessary |

| | |Pneumonia vaccines, Hepatitis B, and other vaccines if you are at risk and meet Medicare Part B coverage rules |

|Inpatient hospital care |Yes |Our plan covers an unlimited number of days for an inpatient hospital stay |

|Inpatient mental health care |Yes |Our plan covers an unlimited number of days for an inpatient hospital stay |

|Medical nutrition therapy |No |This 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 that |

|Medicare Diabetes Prevention Program (MDPP) |No |MDPP services will be covered for eligible Medicare beneficiaries |

|Medicare Part B prescription drugs |Yes |Step Therapy may apply to certain drugs. |

|Medicare Part D prescription Drugs |Yes |Consult Formulary for PA requirements on certain drugs EnvisionRx 1-800-361-4542 |

| | |Tier 1 and 2 are excluded from the $275 Part D deductible |

| | |Additional Gap Coverage provided for Tier 1 in the Gap Coverage Stage |

|Obesity screening and therapy to promote sustained weight |No |If you have body mass index 30 or more |

|loss | | |

|Other Health Care Professional Services |Yes |We cover services provided by other health providers, such as physician Assistants, nurse practitioners, social workers, and |

| | |psychologists. Coverage can also include a health educator, a registered dietitian, or nutrition professional, or other licensed |

| |(Prior Authorization is not |practitioner or a team of such medical professionals, working under the direct supervision of a Physician. |

| |required for Nurse Practitioner| |

| |and Physician Assistant) | |

|Outpatient diagnostic tests and therapeutic services and |No |Preventive Diagnostic procedures and tests |

|supplies (Part 1)* | |X-Rays |

| |(Prior Authorization is needed |Lab services |

| |for tests that require |Diagnostic procedures and tests such as: |

| |contrasts or Anesthesia) |-Echocardiogram |

| | |-EKG |

| | |-Sonogram |

| | |-Ultrasound |

|Outpatient diagnostic tests and therapeutic services and |Yes |Surgical and medical supplies |

|supplies (Part 2)* | |Blood Services- Coverage begins with the first pint (3-pint deductible is waived) |

| | |Therapeutic radiological services |

| | |Diagnostic radiological services (CT, MRI, PET scan, MRA, etc) |

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|Outpatient hospital services |Yes |We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or |

| | |injury |

| |(Prior Authorization is not |Covered services include, but are not limited to: |

| |required for tests such as |Services in an emergency department or outpatient clinic, such as observation services or outpatient surgery |

| |Sonogram/ |Laboratory and diagnostic tests billed by the hospital |

| |Ultrasound, Electrocardiogram, |Mental health care, including care in a partial-hospitalization program, if a doctor certifies that inpatient treatment would be |

| |X-Ray and Lab) |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 yourself |

|Outpatient mental health care |Yes - for tests that require |Cover individual or group outpatient mental health care |

| |Anesthesia | |

| |(Prior Authorization is not | |

| |required for tests such as | |

| |cognitive skills testing, | |

| |psychological and neurological | |

| |testing. Also psychiatrist, | |

| |nurse practitioner, & physician| |

| |assistant) | |

|Outpatient rehabilitation services |Yes |Occupational therapy |

| | |Physical therapy |

| | |Speech-language pathology (Speech therapy) |

|Outpatient substance abuse services |Yes |Cover individual and group outpatient substance abuse services |

|Outpatient surgery, including services provided at |Yes |Outpatient Surgery includes services provided at hospital outpatient facilities and ambulatory surgical centers. |

|hospital outpatient facilities and ambulatory surgical | | |

|centers | | |

|Over-The-Counter benefit |Not Covered | |

|Partial hospitalization services |Yes | |

|Physician/Practitioner services, including doctor’s office|No |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 |

| |(Prior Authorization is needed |any lab or diagnostic testing performed during your visit. |

| |for tests that require | |

| |Contrasts or Anesthesia) | |

|Podiatry services |No |Nail debridement and clipping |

| | |Must meet Medicare criteria for Podiatry services |

|Prostate cancer screening exams |No |For men age 50 and older once every 12 months: digital rectal exam or prostate specific antigen test |

|Prosthetic devices and related supplies |Yes | |

|Pulmonary rehabilitation services |Yes |Limited to up to 36 sessions, no more than two sessions per day |

|Screening and counseling to reduce alcohol misuse |No |One alcohol misuse screening for adults who misuse alcohol but aren’t alcohol dependent but if you screen positive for alcohol |

| | |misuse, you get up to 4 face-to-face counseling sessions per year |

|Screening for lung cancer with low dose computed |No |Covered once every 12 months for people 55-77 years who have a history of tobacco smoking |

|tomography | | |

|Screening for sexually transmitted infections (STIs) and |No |Cover tests once every 12 months or at certain times during pregnancy |

|counseling to prevent STIs | |Cover up to 2 individual 20 to 30 minutes face-to-face counseling sessions each year |

|Services to treat Kidney disease and conditions |Yes |Kidney disease education |

| | |Dialysis |

|Skilled nursing facility (SNF) care |Yes |We cover 100 days in a SNF during each benefit period. |

| | |The 3 day inpatient hospital stay prior to SNF admission is waived. |

|Smoking and tobacco use cessation (counseling to stop |No |If you use tobacco but do not have signs of tobacco related disease we cover two counseling sessions within a 12 month period (Each |

|smoking or tobacco use) | |counseling attempt includes up to 4 face-to-face visits) |

|Supervised Exercise Therapy (SET) |Yes |Up 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 Services |Yes (referral may also be |Model of care intended to reduce avoidable hospital admissions for members living with chronic conditions and transitioning from home |

| |required) |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”. |

|Transportation |Not Covered | |

|Urgently needed services |No |If you are admitted to the hospital within 24 hours for the same condition, you do not pay the copay |

|(US + Territories Only) | | |

|Vision Care |(Contact National Vision | |

|Eye exams |Associates 1-844-344-1250 for |High risk of Glaucoma 1 screening per year |

|Glaucoma screening |coverage and authorization) |For people with diabetes one screening for diabetic retinopathy per year |

| | |One pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery that implants an intraocular lens. |

|Vision Care (Optional Supplemental Benefit) |Yes (Contact National Vision |Optional Vision Benefit: |

| |Associates 1-844-344-1250 for |1 Routine Eye Exam per Year |

|Eye exam |coverage and authorization) | |

|Eye wear | |Up to $275 for eyeglasses |

|“Welcome to Medicare” Preventive visit |No |One time visit only within the first 12 months you have Medicare Part B. |

| | | |

| | |Medicare-covered EKG following Welcome Visit Preventive Services at no additional cost. |

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