All Plans are available in New York (Manhattan), Bronx, Queens, Kings (Brooklyn), Nassau & Westchester counties.

CareWell is also available in Suffolk county.

AgeWell New York Medicare Advantage with Prescription Drug Plans (HMO) 2020

Benefits Overview

If you have Medicare

LiveWell (HMO) H4922-011

If you have Medicare and full Medicaid† or Qualified Medicare Beneficiary (QMB) Only

FeelWell (HMO D-SNP) Dual Special Needs Plan H4922-003

If you have Medicare and reside in a contracted long term nursing care facility

CareWell (HMO I-SNP) Institutional Special Needs Plan H4922-004

Monthly Premium $36.60 (derived from Part D/LIS applies)

$0* $0 or up to $36.60*

Part D Deductible $290 (Tiers 1 & 2 excluded) $0* $0 or $89 or $435* Physician Care Primary Care $15 copay ($0 annual routine physical

exam) $0* $0 or 20% coinsurance*

Specialists (No Referrals) $40 copay $0* $0 or 20% coinsurance*

Physical Therapy $25 copay $0* $0 or 20% coinsurance*

Part C Deductible $600 deductible for inpatient hospital, outpatient surgery & dialysis

$0 $0* or same as Original Medicare

MOOP Maximum Out Of Pocket (MOOP)

$6,700 $3,400* $6,700*

Hospital/ Facility Care

Hospital–Inpatient $340 copay per day for days 1-5; $0 copay per day for days 6-90 (3-day IP Hospital stay waived for SNF)

$0* (3-day IP Hospital stay waived for SNF)

$0* or same as Original Medicare

Outpatient Surgery $450 copay $0* $0 or 20% coinsurance*

Emergency Services

ER Visits (US & Territories) $90 copay $0* $0 or 20% coinsurance* up to $90

Urgent Care (US & Territories) $40 copay $0* $0 or 20% coinsurance* up to $65

Diagnostics Lab & X-Ray Lab Services: $15 copay at labs or doctor offices $40 copay at outpatient hospital X-Ray: $30 copay

$0* $0 or 20% coinsurance*

Tests & Procedures $20 copay at doctor offices or free standing clinics $30 copay at outpatient hospital

$0* $0 or 20% coinsurance*

MRI and CT scans $250 copay $0* $0 or 20% coinsurance*

Prescription Drug Coverage

Part D Prescription Drug Coverage (30-Day Supply)

Tiers (1-5): T1: $3, T2: $12, T3: $47, T4: $100 copay T5: 27% coinsurance

Generic Copay: $0 or $1.30 or $3.60* All other drugs Copay: $0 or $3.90 or $8.95*

Generic Copay: $0 or $1.30 or $3.60* All other drugs Copay: $0 or $3.90 or $8.95* or 15% or 25% coinsurance*

Save Money with Mail Order (90-Day Supply)

T1: $0, T2: $18, T3: $117.50, T4: $250, T5: 27% coinsurance

Save money with a 90-day supply N/A

Coverage Through the Gap Tier 1: $3 copay $0 for mail order

There is No coverage gap stage (Donut Hole) for this plan (copay based on level of Extra Help)

Depends on your level of “Extra Help”**

OTC N/A $150 / per quarter N/A

Vision, Dental & Hearing

Vision $0 for annual routine eye exam Optional benefit: $9 Monthly Premium Our plan pays up to $275 every year for eyeglasses

$0 for annual routine eye exam; Our plan pays up to $150 every year for eyeglasses

$0* or 20% coinsurance for eye exam; eyewear only after cataract surgery

Dental Optional benefit: $16 monthly premium preventive and comprehensive services no maximum amount limit

$0 comprehensive services $1,500 Maximum Benefit Limit

$0 comprehensive services $1,200 Maximum Benefit Limit

Hearing $0 for annual routine hearing exam Our plan pays up to $1,000 every 2 years for hearing aids

$0 for annual routine hearing exam Our plan pays up to $1,000 every 2 years for hearing aids

$0 for annual routine hearing exam Our plan pays up to $500 every 2 years for hearing aids

Alternative Treatments

Acupuncture $10 copay - 10 treatments per year $0 copay - 6 treatments per year N/A

Chiropractor $20 copay $0* $0 or 20% coinsurance*

Wellness/ Preventive Care

Wellness/Fitness Program SilverSneakers

SilverSneakers - $0 SilverSneakers - $0 N/A

Rewards & Incentive Program Available for all members - meet required health care actions. Ask your Wellness Coach

Available for all members - meet required health care actions. Ask your Care Manager

Available for all members- meet required health care actions. Ask your Care Manager

Screenings & Immunizations $0 $0 $0

Diabetic Supplies $0 (FreeStyle and OneTouch) $0 (FreeStyle and OneTouch) $0 (FreeStyle and OneTouch)

Personal Care Manager or Wellness Coach

Wellness Coach to help access health care benefits

Care Manager to coordinate benefits Nurse Practitioner and a Licensed Masters Social Worker to coordinate benefits

Transportation N/A $0 copay 4 one-way trips post hospitalization (Contact Care Manager on how to access Medicaid trips)

N/A

*Depending on your level of Medicaid/MSP and Extra Help ** Some members may pay up to 25% of the cost of generic drugs and 25% for brand name drugs. This is an overview of covered benefits only, for more details refer to the Evidence of Coverage. This plan uses a formulary. Limitations may apply.

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2020Medicare Advantagewith PrescriptionDrug Plans (HMO MAPD)Health plan options with value added benefits.

The Way to Age Well in New York

1.866.237.3210 | agewellnewyork.com

The Way to Age Well in New York.New York is home to the Empire State Building, the Brooklyn Bridge and Times Square. But, most of all, New York is home to you. Looking out for New Yorkers the best way we know how, AgeWell New York Health Plans are your way to stay healthy and age well in New York with Medicare coverage you need the most.

Our Medicare Advantage with Prescription Drug Plans are personalized, easy to understand, and include plan options for those with Medicare and those with Medicare and Medicaid.

Health care coverage includes:

•Access to a large network of physicians, hospitals and specialty services in your community.

• Wellness and preventive services to keep you healthy.

•Fitness programs to maintain your quality of life.

•AgeWell New York professional care team includingdoctors, nurses and social workers to help optimizeyour health care coverage and access to services.

•All original Medicare benefits (Part A and B).

•Full prescription drug coverage (Part D).

•Access to supplemental benefits above what Original Medicare covers.

Health Plan Options

LiveWell (HMO) Medicare Advantage with Prescription Drug Plan (MAPD) for Medicare eligible beneficiaries. FeelWell (HMO D-SNP) (Dual Special Needs Plan) For Medicare beneficiaries with full Medicaid †, SLMB Plus, QMB Plus or QMB only. CareWell (HMO I-SNP) (Institutional Special Needs Plan) For Medicare beneficiaries residing in a contracted long term nursing care facility.

Navigating Medicare enrollment as you turn 65

For most people, turning 65 means you’re eligible for Original Medicare, Part A (hospital stays), and Part B (doctor visits).

At this time, you may also choose to enroll in Medicare Part C, also kno wn as a Medicare Advanta ge Plan. At AgeWell New York, we offer Medicare Advanta ge with Prescription Drug Plans. You must be entitled to Medicare Part A and be enrolled in Medicare Part B, live in our ser vice area, and cannot ha ve End Sta ge Renal Disease (ESRD) a t the time of enrollment.

Let AgeWell New York Health Plans help guide you through these steps to make a well-made choice for your overall wellness. Our Senior Benefits Advisors can assist you in understanding Original Medicare and give you options for a Medicare Advanta ge Plan tha t’s right for you.

Consultations available

At your request, you can meet with one of our Senior Benefits Advisors for an in-person consultation at no cost.

Contact AgeWell New York Health Plans to learn about eligibility requirements and which plan is right for you.

| | | Toll Free 1.866.237.3210 TTY/TDD 1.800.662.1220 info@agewellnewyork.com agewellnewyork.com

At AgeW ell New York we want you to keep on living as healthy as you can.

AgeWell New York Health Plans give you flexibility in choosing health care coverage that’s right for you, and helps maintain your overall health and well-being. Plan options are available for those with Medicare and those with Medicare and Medicaid residing in the New York Metropolitan area including New York (Manhattan), Bronx, Queens, Kings (Brooklyn), Nassau, Suffolk and Westchester counties.

We’re herefor your call.

For eligibility and enrollment contact AgeWell New York Health Plans

Toll Free 1.866.237.3210TTY/TDD 1.800.662.1220

Hours are 7 days a week from 8:00 a.m. to 8:00 p.m. agewellnewyork.com info@agewellnewyork.com

AgeWell New York, LLC is a HMO plan with a Medicare and Medicaid contract. Enrollment in AgeWell New York, LLC depends on contract renewal. This information is not a complete description of benefits. Call 1-866-237-3210 (TTY/TDD: 1-866-662-1220) for more information. Hours are 7 days a week from 8:00 am to 8:00 pm. Note: From April 1 to September 30, we may use alternate technologies on Weekends and Federal holidays. ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call 1-866-237-3210 (TTY/TDD: 1-800-662-1220). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-237-3210 (TTY/TDD: 1-800-662-1220). AgeWell New York complies with applicable Federal civil rights laws and does not discriminate on the basis of races, color, national origin, age, disability, or sex. AgeWell New York cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. H4922_AS4041_M Accepted 09162019

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