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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 High Deductible Health Plan
Insurance for Employees
and Retirees
(PO7)


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 High Deductible Health Plan the combined prescription drug and medical out-of-pocket limit (OOPL), or maximum, you would pay for Levels 1 through 4 drugs is $2,500 for individual coverage and $5,000 for family coverage. All covered prescription drugs (Rx) 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.

Provided By NAVITUS HEALTH SOLUTIONS
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  IYC Local HDHP IYC Local Access HDHP
In-Network
IYC Local Access HDHP
Out-of-Network
IYC Medicare, Medicare Advantage and Medicare Plus
  Deductible1
An annual fixed dollar amount a member pays before the plan pays.
  $1,500 / $3,000 (combined medical & Rx) $1,700 / $3,400 (combined medical & Rx) $2,000 / $4,000 (combined medical & Rx) None
  Copayment/Coinsurance
A dollar amount or percentage a member pays for each covered drug.
Level 1 $5 $5 $5 $5
Level 2 20% ($50 max) 20% ($50 max) 20% ($50 max) 20% ($50 max)
Level 3 40% ($150 max) 40% ($150 max) 40% ($150 max) 40% ($150 max)2
Level 4 Preferred drugs $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)
  Out-of-Pocket Limits4
The maximum amount of copayments, coinsurance or deductible that a member pays.
Levels 1 & 2 $2,500 / $5,000 (combined medical & Rx) $3,500 / $6,550 (combined medical & Rx) $3,800 / $7,600 (combined medical & Rx) $600 / $1,2005
Level 3 $6,850 / $13,7002,6
Level 44 $1,200 / $2,4004

 

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. All other Level 4 drugs require coinsurance of 40% ($200 max).
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.

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 12:08:47 PM