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Wisconsin Department of Employee Trust Funds header image It's Your Choice 2017 State of Wisconsin Group Health Insurance Program
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2017 It's Your Choice - State of Wisconsin Group Health Insurance for Employees and Retirees

Wisconsin Department Of Employee Trust FundsIt's Your Choice 2017


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

Pharmacy Benefits for Retirees without Medicare

If you are a retiree with Medicare, see Medicare pharmacy benefits. If you are an active employee (or on COBRA), see active pharmacy benefits.

Provided by NAVITUS HEALTH SOLUTIONS
Navitus Toll-Free Customer Care—1-866-333-2757
www.navitus.com

The 2017 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 Health 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 (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.

 

  IYC Health Plan
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 individual / $3,000 family (combined medical & Rx) None None $1,700 individual / $3,400 family (combined medical & Rx) $2,000 individual / $4,000 family (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 individual / $1,200 family $2,500 individual / $5,000 family (combined medical & Rx) $1,000 individual / $2,000 family $1,000 individual / $2,000 family $3,500 individual / $6,550 family $3,800 individual / $7,600 family
Level 3 $6,850 individual / $13,700 family2,6 $6,850 individual / $13,700 family2,6 None
Level 44 $1,200 individual / $2,400 family $1,200 individual / $2,400 family $1,200 individual / $2,400 family

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.

Note: Unless a drug is considered preventive, anyone on the HDHP plan is responsible for the full amount of the drug cost until the deductible is met, then the copays take effect until the out-of-pocket limit is met.

Prescription Drug Formulary
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.

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 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, 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.

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: 10/3/2016 2:41:00 PM