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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

Local Deductible Plan
Insurance for Employees
and Retirees

How much are my prescription drugs?

The 2016 Pharmacy Benefits Plan Comparison table below shows what amount or percentage you would pay for prescription drugs under each plan. For example, with the It’s Your Choice Local Deductible Plan the out-of-pocket limit (OOPL), or maximum, you would pay for Levels 1 and 2 drugs is $600 for individual coverage and $1,200 for family coverage. All covered prescription drugs fall into one of four cost-sharing levels, including Level 1 for most generic drugs and Levels 2, 3 and 4 for most brand-name drugs.

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  IYC Local Deductible
(also Medicare, Medicare Plus and Medicare Advantage)
IYC Local Access Health Plan
IYC Local Access Health Plan
An annual fixed dollar amount a member pays before the plan pays.
  None None None
A dollar amount or percentage a member pays for each covered drug.
Level 1 $5 $5 $5
Level 2 20% ($50 max) 20% ($50 max) 20% ($50 max)
Level 3 40% ($150 max)1 40% ($150 max)1 40% ($150 max)1
Level 4 Preferred drugs $502 or 40% ($200 max) $502 or 40% ($200 max) $502 or 40% ($200 max)
Level 4 Non-preferred drugs3 40% ($200 max) 40% ($200 max) 40% ($200 max)
  Out-of-Pocket Limits
The maximum amount of copayments, coinsurance or deductible that a member pays.
Levels 1 & 2 $600 / $1,2004 $1,000 / $2,0004 $1,000 / $2,0004
Level 3 $6,850 / $13,7001,5 $6,850 / $13,7001,5 None
Level 43 $1,200 / $2,400 $1,200 / $2,400 $1,200 / $2,400


1 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).
2 Reduced copayment of $50 applies only when Preferred Specialty Drugs are obtained from a Preferred Specialty Pharmacy.
3 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.
4 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.
5 Federal Maximum out-of-pocket Limit or MOOP.

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: 9/25/2015 12:35:40 PM