Find answers to many frequently asked questions including detailed information regarding enrollment and plan change opportunities during and beyond the annual It’s Your Choice (IYC) open enrollment period.
Find answers to many frequently asked questions including detailed information regarding enrollment and plan change opportunities during and beyond the annual It’s Your Choice (IYC) open enrollment period.
Medicare pays: Allowable services after Part A ($1,316) and Part B ($183) deductibles
Plan pays: Part A inpatient hospital deductible of $1,316 and Part B deductible of $183
You pay: $0
Medicare pays: Allowable services after Part A ($1,316) and Part B ($183) deductibles
Plan pays: Plan pays: Part A inpatient hospital deductible of $1,316 and Part B deductible of $183
You pay: $0
Annual Medical Coinsurance1
Medicare pays: For Part A, varying coinsurance as listed below for hospital inpatient and skilled nursing facility care. After Part B deductible, 80%
Plan pays: Part B deductible and 20% coinsurance
You pay: $0
Medicare pays: For Part A, varying coinsurance as listed below for hospital inpatient and skilled nursing facility care. After Part B deductible, 80%
Plan pays: Part B deductible and 20% coinsurance
You pay: $0
Annual Medical Out-of-Pocket Limit (OOPL)
None
None
Outpatient illness/injury related services
Medicare pays: After Part B deductible, 80%
Plan pays: Part B deductible and 20%
coinsurance
You pay: $0
Medicare pays: After Part B deductible,
80%
Plan pays: Part B deductible and 20%
coinsurance
You pay: $0
Emergency Room Copay
Medicare pays: After Part B deductible, 80%
Plan pays: Part B deductible and 20%
coinsurance
You pay: $60 copayment (Waived if admitted
as an inpatient directly from the emergency
room or for observation for 24 hours or longer)
Medicare pays: After Part B deductible,
80%
Plan pays: Part B deductible and 20%
coinsurance
You pay: $0
Hospital Semiprivate room and board, and miscellaneous hospital services and supplies such as drugs, X-rays, lab tests and operating room. “Lifetime reserve” days are a one-time additional 60 days of hospital coverage paid by Medicare.
Medicare pays: After Part A deductible; full
cost for the first 60 days
61st to 90th day, all but $329 per day
91st to 150th day, all but $658 per day (if
using “lifetime reserve”), if “lifetime reserve”
days are exhausted, $0
Plan pays: 100% as medically necessary,
plan providers only. No day limit
You pay: $0
Medicare pays: After Part A deductible; full cost for the first 60 days
61st to 90th day, all but $329 per day
91st to 150th day, all but $658 per day (if using “lifetime reserve), if “lifetime reserve” days are exhausted, $0
Plan pays: Initial Part A deductible of $1,316 for the first 60 days
61st to 90th day, $329 per day
91st to 150th day, $658 per day if under “lifetime reserve” period
You pay: $0 for first 90 days of confinement, and up to 150 under “lifetime reserve.” Once “lifetime reserve” is exhausted, you pay the full cost after 90 days
Licensed Skilled Nursing Facility
Medicare covered services in a Medicare approved facility
Medicare pays: Requires a 3-day period of hospital stay, 100% for the first 20 days
21st to 100th days, all but $164.50 per day
Beyond 100 days, $0
Plan pays: 100% as medically necessary, for the first 120 days per benefit period; plan providers only
Beyond 120 days, $0
You pay: $0 for the first 120 days, full cost after 120 days
Requires a 3-day period of hospital stay
Medicare pays: 100% for the first 20 days
21st to 100th days, all but $164.50 per day
Beyond 100 days, $0
Plan pays: 21st to 100th days, $164.50 per day 101st to 120th days, all covered services up to a maximum of 120 days per benefit period
Beyond 120 days, $0
You pay: $0 for the first 120 days, full cost after 120 days
Licensed Skilled Nursing Facility
(Non-Medicare approved
facility) If admitted within 24
hours following a hospital stay
Medicare pays: $0
Plan pays: 120 days per benefit period for skilled care in a facility licensed in a state
You pay: Full cost after 120 days
Medicare pays: $0
Plan pays: Maximum daily rate for up to 30 days per confinement; covers only the same type of expenses normally covered by Medicare in a Medicare-approved facility
You pay: $0 for eligible expenses for the
first 30 days, full cost after 30 days
Medical Supplies, Durable Medical Equipment and Durable Diabetic Equipment and Related Supplies
For Medicare-approved supplies:
Medicare Pays: After Part B deductible, 80%
Plan pays:
If you have not met the Part B deductible, 80%
If you have met the Part B deductible, but you have not met the $500 OOPL per participant, 0%
If you have met the Part B deductible, and also the $500 OOPL per participant, 20%
You pay: 20% up to $500 OOPL per participant, after OOPL, $0
For Medicare-approved supplies:
Medicare Pays: After Part B deductible, 80%
Plan pays: Part B deductible and 20% coinsurance
You pay: $0
For supplies NOT covered by Medicare:
Medicare pays: None
Plan pays:
If you have not met the $500 OOPL per participant, 80%
If you have met the $500 OOPL per participant, 100%
You pay: 20% up to $500 OOPL per participant, after OOPL, $0
For supplies NOT covered by Medicare:
Medicare pays: None
Plan pays: None
You pay: Full cost of supplies
Home Health Care Under an approved plan of care, part-time services of an RN, LPN or home health aide; physical, respiratory, speech or occupational therapy; medical supplies, drugs, lab services and nutritional counseling.
Medicare pays: 100% of charges for visits considered medically necessary by Medicare, generally 5 visits per week for 2 to 3 weeks; or 4 or fewer visits per week as long as required
Plan pays: 100% for 50 visits per year, plan may approve an additional 50 visits
IYC Medicare Advantage has no visit limits
You pay: Full costs of visits not covered by
Medicare and the plan beyond the 50 (or if
approved, 100) visits per year
Medicare pays: 100% of charges for
visits considered medically necessary by
Medicare, generally 5 visits per week for
2 to 3 weeks; or 4 or fewer visits per week
as long as required
Plan pays: 100% for up to 365 visits per
year
You pay: Full costs of visits beyond 365
per year
Hearing Exam
For routine exams:
Medicare Pays: None
Plan pays: 100%
You pay: $0
For routine exams:
Medicare pays: None
Plan pays: None
You pay: Full cost of hearing exam
For illness or disease:
Medicare pays: After Part B deductible, 80%
Plan pays: Deductible and 20% coinsurance
You pay: $0
For illness or disease:
Medicare pays: After Part B deductible,
80%
Plan pays: Deductible and 20%
coinsurance
You pay: $0
Hearing Aid (per ear)
Medicare pays: No coverage for adults
Plan pays: 80% for adults up to plan paid
$1,000 every three years (does not count
toward OOPL)
You pay: 20% coinsurance and 100% of
costs exceeding plan payment of $1,000
Medicare pays: No coverage for adults
Plan pays: None
You pay: Full cost of hearing aid
Prescription Deductible
None
None
Prescription Copay
Level 1
$5
$5
Level 2
20% ($50 max)
20% ($50 max)
Level 3
40% ($150 max)
40% ($150 max)
Level 4 Specialty3
$50 copay
(If filled at Lumicera or UW Specialty Pharmacies)3
$50 copay
(If filled at Lumicera or UW Specialty Pharmacies)3
Preventive
Plan pays: 100%, regardless of deductible
Plan pays: 100%, regardless of deductible
Prescription Out-of-Pocket Limit
Levels 1 & 2 - Individual / Family
$600 / $1,200
$600 / $1,200
Level 3 - Individual / Family
$6,850 / $13,700
$6,850 / $13,700
Level 4 - Individual / Family
$1,200 / $2,400
$1,200 / $2,400
OOPL = out-of-pocket limit
1Medicare deductible and coinsurance amounts listed are from 2017. Medicare deductible amounts are listed only to describe how your benefits work under the available plan designs. Your out-of-pocket costs are indicated in the "You pay" line.
2IYC Medicare Plus pays only for services that Medicare covers. You pay the full cost of any non-covered services.
3If you fill a Level 4 Specialty prescription at a non-preferred specialty pharmacy (listed above) you will pay 40% ($200 max). The amounts paid will not apply to the Level 4 OOPL, rather, to a federal limit of $6,850 individual / $13,700 family.
The most up-to-date formulary information is available on the Navitus MedicareRx website. Go to the Navitus MedicareRx website and select the "Members" tab at the top of the page, then you can log in. Once logged in you can select he "Formulary" link You may also call Navitus Customer Care toll free at 1-866-333-2757 with questions about the formulary.
Some prescription drugs require a prior authorization for it to be covered by the program. A prior authorization is initiated by the prescribing physician on behalf of the member. Navitus will review the prior authorization request within two business days of receiving all necessary information from your physician. Medications that require prior authorization for coverage are marked with “PA” on the formulary.
A 90-day supply of most maintenance medications can be purchased at your retail pharmacy. To take advantage of this program, you must have three consecutive claims already processed for that drug in the Navitus claims system immediately before the 90-day supply is requested. In addition, your doctor must write the prescription specifically for a 90-day supply. Three copayments are still required. More information can be found on the Navitus website or by calling Navitus Customer Care.
Serve You is the new mail order vendor. Up to a 90-day supply of Level 1 and Level 2 medications can be purchased for only two copayments through our mail order service. Level 3 medications may also be available for up to a 90-day supply, but three copayments will apply. More detailed information can be found on the Navitus website, Serve You website or by calling Navitus Customer Care.
By splitting a higher-strength tablet in half to provide the needed dose, you receive the same medication and dosage while buying fewer tablets and saving on copayments. Medications included in the program are marked with “¢” on the Navitus formulary. Members may obtain tablet splitting devices at no cost by calling Navitus Customer Care.
(Level 4 Self-Injectables and Specialty Medications)
If you are taking a specialty medication, the Navitus SpecialtyRx Program is offered at a reduced price through both Lumicera Specialty Pharmacy and the UW Specialty Pharmacy. You can also fill your prescription at another specialty pharmacy, see cost information above. Specialty medications are marked with “ESP” in the formulary. To begin receiving your self-injectable and other specialty medications from the specialty pharmacy, please call Navitus SpecialtyRx Customer Care at 1-877-651-4943.
Coordination of benefits applies when, as determined by the order of benefit determination rules, you have primary coverage under Medicare or another policy and Navitus is your secondary coverage. Navitus covers the remaining cost of any covered prescriptions up to the allowed amount under your Group Insurance plan. Coordination of benefits does not guarantee that all your out-of-pocket costs will be covered.
Disclaimer:
Every effort has been made to ensure that this information is accurate, but may be subject to change. Please note revision dates located at the bottom of each page. In the event of conflicting information, federal law, state statute, state health contracts and/or policies and provisions established by the State of Wisconsin Group Insurance Board shall be followed.
This page was last modified on: 11/13/2017 11:21:34 AM
It's Your Choice 2018
