This chart compares your medical benefit options. This is not a complete description of coverage, you can find that in the Certificates of Coverage.
|
IYC Local Deductible |
IYC Local Access Deductible Plan
In-Network |
IYC Local Access Deductible Plan
Out-of-Network |
Annual Medical Deductible |
$500 individual / $1,000 family
When an individual within a family plan meets the $500 deductible, benefits apply as described below
Deductible applies to annual out-of-pocket limit (OOPL)
Medical deductible does not apply to prescription drugs |
$1,000 individual / $2,000 family
When an individual within a family plan meets the $1,000 deductible, benefits apply as described below
Deductible applies to annual out-of-pocket limit (OOPL)
Medical deductible does not apply to prescription drugs |
Annual Medical Coinsurance |
After deductible: Plan pays 100% for most services, except for durable medical equipment, certain hearing aids and cochlear implants. See below. |
After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL
Applies to medical services |
Annual Medical Maximum
Out-of-Pocket Limit (OOPL) |
Only applies to durable medical equipment (see separate OOPL below), certain hearing aids and cochlear implants.
$6,850 individual / $13,700 family for federally required essential health benefits |
$4,000 individual $8,000 family (includes deductible) |
Routine, preventive services as required by federal law |
Plan pays 100%
For details, visit
healthcare.gov
|
After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL |
Illness/injury related services |
After deductible: Plan pays 100% |
After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL |
Emergency Room Copay (Waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer.) |
After deductible: You pay $60 copay per visit |
After deductible: You pay $75 copay, after copay in-network deductible and 30% coinsurance up to OOPL |
Vision Exam |
Routine exam: After deductible plan pays 100% for one routine eye exam per year
Illness or injury: After deductible plan pays 100% for adults or children |
Routine exam: No benefit
Illness or injury: After deductible plan pays 70% for adults or children; you pay 30% coinsurance up to OOPL |
Hearing Exam |
After deductible: Plan pays 100% |
After deductible: Plan pays 70% only when exam is for illness or disease; you pay 30% coinsurance up to OOPL |
Hearing Aid
(per ear) |
Every 3 years:
Adults: After deductible plan pays 80% up to $1,000 benefit limit, you pay 20% coinsurance for the first $1,000 and the full cost after
Children: After deductible, plan pays 100% |
Every 3 years:
Adults: No benefit
Children: After deductible, plan pays 70%, you pay 30% coinsurance up to OOPL |
Cochlear Implants |
Adults: After deductible you pay 20% coinsurance for device, surgery, follow-up sessions (not to OOPL); plan pays 100% for hospital charge for surgery
Dependents under age 18: Plan pays 100% for all services |
Dependents under age 18: After deductible plan pays 70%, you pay 30% coinsurance up to OOPL for device, surgery, follow-up sessions |
Durable Medical Equipment |
After deductible: Plan pays 80%, you pay 20% coinsurance up to $500 OOPL per person |
After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL |
Physical/Speech/Occupational Therapy
| After deductible: Plan pays 100% for a combined 50 visits per year (amongst all therapies); plan may approve an additional 50 visits per therapy type
per year |
After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL for a combined 50 visits per year (amongst all therapies); plan may approve an additional 50 visits per therapy type per year |
Skilled Nursing Facility
(non-custodial care) |
After deductible: Plan pays 100% for 120 days
per benefit period |
After deductible: Plan pays 70% for 120 days per benefit period; you pay 30% coinsurance up to OOPL |
Home Health
(Non-custodial)
| After deductible: Plan pays 100% for 50 visits per year. Plan may approve an additional 50 visits |
After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL for 50 visits per plan year. Plan may approve an additional 50 visits |
Mental Health/Alcohol & Drug Abuse |
Outpatient, inpatient and covered transitional services: After deductible: plan pays 100% |
Outpatient, inpatient and covered transitional services: After deductible: Plan pays 70%, you pay 30% member cost up to OOPL |
Transplants |
After deductible: plan pays 100%: Bone marrow, parathyroid, musculoskeletal, corneal, kidney, heart, liver, kidney with pancreas, heart with lung, and lung |
After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL: Includes bone marrow, parathyroid, musculoskeletal, corneal, kidney, with pancreas, heart with lung, and lung |
Precertification for hospitalizations, high-tech radiology and low back surgery |
Varies by plan. See plan descriptions and contact your plan |
Varies by plan. See plan descriptions and contact your plan |
Referrals |
In-network: varies by plan. See plan descriptions and contact your plan
Out-of-network: referral is required |
Not required |
Treatment for morbid obesity |
Excluded |
Excluded |
Oral Surgery |
After deductible: plan pays 100% for 11 procedures |
After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL for 11 procedures |
| |
IYC Local Deductible |
IYC Local Access Deductible Health Plan
In-Network |
IYC Local Access Deductible Health Plan
Out-of-Network |
| Prescription Deductible |
None |
Must use in-network Pharmacy |
Prescription Copay
Level 1
|
$5
|
| Level 2 |
20% ($50 max) |
| Level 3 |
40% ($150 max) |
| Level 4 Specialty |
$50 copay
(Must be filled at Lumicera or UW Specialty Pharmacies) |
| Preventive |
Plan pays: 100%, regardless of deductible |
Prescription Out-of-Pocket Limit
Levels 1 & 2 - Individual / Family
|
$600 / $1,200
|
| Level 3 - Individual / Family |
$6,850 / $13,700 |
| Level 4 - Individual / Family |
$1,200 / $2,400 |
“Zero Dollar” preventive drugs identified by the Affordable Care Act (ACA) are paid for by the program even if the deductible has not been met. You can find a list here.
“First Dollar” preventive drugs identified by the ACA are subject to copayment/coinsurance cost sharing, even if the deductible has not been met. After the deductible is met, the member is still responsible for the copayment/coinsurance until the OOPL is met. You can find a list here.
The most up-to-date formulary information is available on the Navitus website through the Navi-Gate for Members web portal. Go to the Navitus website and select the "Members" option on the left side of the page, then click on the "Member Login" link. Once logged in you can select he "Formulary" link on the left side of the page. 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.
Diabetic supplies and glucometers are covered; you will pay 20% coinsurance. If you are a High Deductible Health Plan participant, you will need to meet your deductible first.
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 through both Lumicera Specialty Pharmacy and the UW Specialty Pharmacy for non-Medicare participants. 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 another policy and Navitus is your secondary coverage. All claims need to be submitted to your other policy first. 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 cover
This page was last modified on: 1/17/2018 10:24:46 AM
It's Your Choice 2018
