My Choice Wisconsin Medicare Dual Advantage Plan (HMO D-SNP)
H5209 - 004 - 0
(4 / 5)
My Choice Wisconsin Medicare Dual Advantage Plan (HMO D-SNP) is a Medicare Advantage (Part C) Special Needs Plan by My Choice Wisconsin Health Plan.
This page features plan details for 2023 My Choice Wisconsin Medicare Dual Advantage Plan (HMO D-SNP) H5209 – 004 – 0 available in Southern, Central and Eastern Wisconsin.
IMPORTANT: This page has been updated with plan and premium data for 2023.
Locations
My Choice Wisconsin Medicare Dual Advantage Plan (HMO D-SNP) is offered in the following locations.
Plan Overview
My Choice Wisconsin Medicare Dual Advantage Plan (HMO D-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Dual-Eligible |
| Conditions Covered: |
| Insurer: | My Choice Wisconsin Health Plan |
| Health Plan Deductible: | $0.00 |
| MOOP: | $8,300 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.
- Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.
Ready to sign up for My Choice Wisconsin Medicare Dual Advantage Plan (HMO D-SNP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 TTY 711.
Mon-Fri 8am-9pm EST | Sat 8am-8pm EST.
Premium Breakdown
My Choice Wisconsin Medicare Dual Advantage Plan (HMO D-SNP) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $164.90 | $0.00 | $0.00 | $0.00 | $164.90 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
My Choice Wisconsin Medicare Dual Advantage Plan (HMO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $505.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Basic |
| Gap Coverage: | No |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $43.40 | $34.80 | $26.30 | $17.70 |
Initial Coverage Phase
After you pay your $505.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
30 Day
90 Day
30 Day
90 Day
| Drug Type | Cost Share |
|---|---|
| Generic drugs | 25% |
| Brand-name drugs | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
My Choice Wisconsin Medicare Dual Advantage Plan (HMO D-SNP) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | 20% coinsurance (limits may apply) (authorization required) (referral not required) |
| Endodontics: | Not covered (no limits) |
| Extractions: | 20% coinsurance (limits may apply) (authorization required) (referral not required) |
| Non-routine services: | Not covered (no limits) |
| Periodontics: | Not covered (no limits) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | 20% coinsurance (limits may apply) (authorization required) (referral not required) |
| Restorative services: | 20% coinsurance (limits may apply) (authorization required) (referral not required) |
Dental (preventive)
| Cleaning: | 20% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | 20% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | Not covered (no limits) |
| Oral exam: | 20% coinsurance (limits may apply) (authorization not required) (referral not required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $0 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | $0 copay (authorization required) (referral not required) |
| Lab services: | $0 copay (authorization required) (referral not required) |
| Outpatient x-rays: | $0 copay (authorization required) (referral not required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $0 copay (authorization not required) (referral not required) |
Emergency care/Urgent care
| Emergency: | $0 copay |
| Urgent care: | $0 copay |
Foot care (podiatry services)
| Foot exams and treatment: | $0 copay (authorization not required) (referral not required) |
| Routine foot care: | Not covered |
Ground ambulance
| $0 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | Not covered (no limits) |
| Hearing aids – inner ear: | Not covered (no limits) |
| Hearing aids – outer ear: | Not covered (no limits) |
| Hearing aids – over the ear: | Not covered (no limits) |
| Hearing exam: | $0 copay (authorization not required) (referral not required) |
Hospital coverage (inpatient)
| $0 copay (authorization not required) (referral not required) |
Hospital coverage (outpatient)
| $0 copay (authorization required) (referral not required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $8,300 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | $0 copay (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | $0 copay (authorization required) |
Medicare Part B drugs
| Chemotherapy: | $0 copay (authorization required) |
| Other Part B drugs: | $0 copay (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $0 copay (authorization required) (referral not required) |
| Outpatient group therapy visit: | $0 copay (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | $0 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit: | $0 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | $0 copay (authorization not required) (referral not required) |
Optional supplemental benefits
| No |
Preventive care
| $0 copay (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | $0 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | $0 copay (authorization required) (referral not required) |
Skilled Nursing Facility
| $0 copay (authorization required) (referral not required) |
Transportation
| Not covered |
Vision
| Contact lenses: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Eyeglass frames: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Eyeglass lenses: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization required) (referral not required) |
| Other: | Not covered (no limits) |
| Routine eye exam: | Not covered (no limits) |
| Upgrades: | $0 copay (limits may apply) (authorization required) (referral not required) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization required) (referral not required) |
Ready to sign up for My Choice Wisconsin Medicare Dual Advantage Plan (HMO D-SNP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 TTY 711. Mon-Fri 8am-9pm EST | Sat 8am-8pm EST.