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Wisconsin Department of Employee Trust Funds header image It's Your Choice 2016 State of Wisconsin Group Health Insurance Program
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Wisconsin Department Of Employee Trust Funds

It's Your Choice 2016


State of Wisconsin
Group Health Insurance Program
(State Employees, Retirees, Continuants and Graduate Assistants)

Pharmacy Benefits for Retirees with Medicare

Provided by Navitus MedicareRx (PDP)
Underwritten by Dean Health Insurance, Inc.
Navitus Toll-Free Customer Care—1-866-270-3877      medicarerx.navitus.com

Each January 1st, all Medicare-eligible participants covered under an annuitant contract will be automatically enrolled in the Medicare Part D prescription drug program called Navitus MedicareRx (PDP), underwritten by Dean Health Insurance, Inc., a Federally-Qualified Medicare Contracting Prescription Drug Plan. Eligible individuals enrolled as members in the Group Health Insurance Program were covered by creditable coverage through Navitus Health Solutions prior to being enrolled in Navitus MedicareRx (PDP).

What does this mean to you?
You do not need to take any further action. You will maintain your current benefits. You will receive a new pharmacy benefit ID card from Navitus MedicareRx that you will need to present to your pharmacy when you fill a prescription. The new ID card will be different than the regular Navitus ID cards issued to active employees and retirees not eligible for Medicare.

When you become eligible for coverage under Medicare Part D, you will be enrolled in the Navitus MedicareRx (PDP) through your employer group coverage. As required by Uniform Benefits, a supplemental wrap benefit is also included to provide full coverage to program members when the Medicare Part D plan does not pay, such as when you are in the deductible phase of Medicare Part D or when you reach the Medicare coverage gap, also known as the “donut hole.” You will be automatically enrolled in this supplemental wrap coverage.

Prescription Drug Benefit

  IYC Health Plan
(also IYC Medicare, Med. Advantage, Med. Plus)
IYC HDHP IYC Access Health Plan
In-Network
IYC Access Health Plan Out-of-Network IYC Access HDHP
In-Network
IYC Access HDHP
Out-of-Network
  Deductible1
An annual fixed dollar amount a member pays before the plan pays.
  None $1,500 / $3,000 (combined medical & Rx) None None $1,700 / $3,400 (combined medical & Rx) $2,000 / $4,000 (combined medical & Rx)
  Copayment/Coinsurance
A dollar amount or percentage a member pays for each covered drug.
Level 1 $5 $5 $5 $5 $5 $5
Level 2 20% ($50 max) 20% ($50 max) 20% ($50 max) 20% ($50 max) 20% ($50 max) 20% ($50 max)
Level 3 40% ($150 max)2 40% ($150 max) 40% ($150 max)2 40% ($150 max)2 40% ($150 max) 40% ($150 max)
Level 4 Preferred drugs $503 or 40% ($200 max) $503 or 40% ($200 max) $503 or 40% ($200 max) $503 or 40% ($200 max) $503 or 40% ($200 max) $503 or 40% ($200 max)
Level 4 Non-preferred drugs4 40% ($200 max) 40% ($200 max) 40% ($200 max) 40% ($200 max) 40% ($200 max) 40% ($200 max)
  Out-of-Pocket Limits5
The maximum amount of copayments, coinsurance or deductible that a member pays.
Levels 1 & 2 $600 / $1,2005 $2,500 / $5,000 (combined medical & Rx) $1,000 / $2,000 $1,000 / $2,000 $3,500 / $6,550 $3,800 / $7,600
Level 3 $6,850 / $13,7002,6 $6,850 / $13,7002,6 None
Level 44 $1,200 / $2,400 $1,200 / $2,400 $1,200 / $2,400

1 “Zero Dollar” preventive drugs identified by the Affordable Care Act (ACA) are paid for by the plan even if the deductible has not been met. “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.
2 Level 3 coinsurance does not apply toward the group health insurance program’s OOPL under a non-HDHP, only the federal maximum out-of-pocket (MOOP).
3 Reduced copayment of $50 applies only when Preferred Specialty Drugs are obtained from a Preferred Specialty Pharmacy.
4 Level 4 coinsurance for Non-preferred Specialty Drugs does not apply to the group health insurance program’s Level 4 OOPL, only the federal MOOP.
5 Family OOPLs for non-HDHP plans are embedded. An individual within a family can reach an individual OOPL before the family OOPL is met and not have to pay any copayment/coinsurance. Family OOPLs for HDHP plans are not embedded and an individual will continue to pay until the family OOPL is met.
6 Federal Maximum Out-of-Pocket Limit or MOOP.

Information regarding your Medicare Part D benefit will be mailed to you by Navitus MedicareRx (PDP) upon confirmed enrollment from Medicare.
Your welcome packet will include the following:

  • Your new ID card
  • Summary of Benefits
  • Pharmacy Directory
  • Formulary
  • Evidence of Coverage (details about your pharmacy coverage)

Medicare Prescription Drug Coverage
All Medicare-eligible retirees, as well as Medicare-eligible dependents of retirees, will be automatically enrolled in the Navitus MedicareRx (PDP), which is underwritten by Dean Health Insurance, Inc., a Federally-Qualified Medicare Contracting Prescription Drug Plan. This is Medicare Part D coverage through an employer group waiver plan.

Prior Authorization Requirements
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 Supply Coverage
Diabetic supplies and glucometers are covered with a 20% coinsurance. In most cases this coinsurance applies to your prescription drug OOPL. Contact Navitus Customer Care if you have questions about your copayment applying to the OOPL.

90-Day-at-Retail Program
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 Navitus’ website or by calling Navitus Customer Care.

Mail Order Program
Up to a 90-day supply of Level 1 and Level 2 medications can be purchased through our mail order service. Some level 3 medications may also be available for up to a 90-day supply. More detailed information can be found on the Navitus website for retirees with Medicare, the WellDyneRx website or by calling Navitus Customer Care. To register for mail order service, call WellDyneRx Customer Care toll free at 1-866-490-3326, 24 hours a day, seven days a week.

RxCENTS Tablet-Splitting Program
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.

Specialty Medication Program
(Self-Injectables and Specialty Medications)

If you are taking a specialty medication, the Navitus SpecialtyRx Program is offered through a partnership with Diplomat Specialty Pharmacy to help coordinate members’ specialty pharmacy needs. Prescriptions for preferred specialty medications, marked with “ESP” in the formulary, that are filled at Diplomat receive a reduced $50 copayment. The reduced copayment does not apply to covered, non-preferred specialty medications or to preferred specialty drugs filled at a pharmacy other than Diplomat, the Preferred Specialty Pharmacy. 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 or visit diplomatpharmacy.com.

Coordination of Benefits
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 of your out-of-pocket costs will be covered.

PLEASE READ THIS IMPORTANT NOTICE CAREFULLY

See also your 2016 Notice of Creditable Coverage for Medicare Part D.
This notice has information about your prescription drug coverage with the program for people with Medicare. 

By completing your enrollment application or maintaining your enrollment with the Group Health Insurance Program, you agree to the following:
I understand that this prescription drug coverage is in addition to my coverage under Medicare; therefore, I will need to keep my Medicare Part A or Part B coverage. It is my responsibility to inform Navitus MedicareRx (PDP) of any prescription drug coverage that I have or may obtain in the future. I can only be in one Medicare prescription drug plan at a time—if I am currently in a Medicare prescription drug plan, my enrollment in Navitus MedicareRx (PDP) will end that enrollment. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes if an enrollment period is available, generally during the Annual Medicare Part D enrollment period (October 15 – December 7), unless I qualify for certain special circumstances.

Navitus MedicareRx (PDP) serves a specific service area. If I move out of the area that Navitus MedicareRx (PDP) serves, I need to notify the plan so I can disenroll and find a new plan in my new area. I understand that I must use network pharmacies except in an emergency when I cannot reasonably use Navitus MedicareRx (PDP) network pharmacies. Once I am a member of Navitus MedicareRx (PDP), I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Navitus MedicareRx (PDP) when I get it to know which rules I must follow to get coverage.

I understand that if I leave this plan and don’t have or get other Medicare prescription drug coverage or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty in addition to my premium for Medicare prescription drug coverage in the future. I understand that if I am getting assistance from a sales agent, broker or other individual employed by or contracted with Navitus MedicareRx (PDP), he/she may be paid based on my enrollment in Navitus MedicareRx (PDP). Counseling services may be available in my state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or prescription drug plan options, medical assistance through the state Medicaid program, and the Medicare Savings Program.

Release of Information:
By joining this Medicare prescription drug plan, I acknowledge that Navitus MedicareRx (PDP) will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Navitus MedicareRx (PDP) will release my information, including my prescription drug event data, to Medicare, who may release it for research and other purposes which follow all applicable federal statutes and regulations. The information on my enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on my form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on my behalf under state law where I live) on my application means that I have read and understand the contents of the application. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under state law to complete the enrollment; and 2) documentation of this authority is available upon request by Medicare or by my employer group.

This notice is provided each year, prior to the next Medicare prescription drug coverage enrollment period or whenever program coverage changes. For more information, please contact ETF or Navitus MedicareRx (PDP).

Navitus MedicareRx (PDP) Customer Care
Call:  1-866-270-3877—Calls to this number are free. Members can reach Navitus Customer Care 24 hours a day/seven days a week, except Thanksgiving and Christmas.
TTY:  711—This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. TTY access is available 24 hours a day/seven days a week, except Thanksgiving and Christmas.

Write:  Navitus MedicareRx (PDP) Customer Care, P.O. Box 1039, Appleton, WI  54912-1039
Website:  medicarerx.navitus.com

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: 8/17/2016 1:06:55 PM