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Wisconsin Department of Employee Trust Funds header image It's Your Choice 2017 Local Traditional Health Plan Insurance Program
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2017 It's Your Choice - Local Traditional Health Plan Insurance for Employees and Retirees
Wisconsin Department Of Employee Trust Funds It's Your Choice 2017


Local Traditional Plan
Insurance for Employees
and Retirees
(PO2, PO12)


How much are my prescription drugs?

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

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 Local Traditional 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.

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

  IYC Local Traditional
IYC Local Access Health Plan
In-Network
IYC Local Access Health Plan
Out-of-Network
  Deductible
An annual fixed dollar amount a member pays before the plan pays.
  None None None
  Copayment/Coinsurance
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 Limits4
The maximum amount of copayments, coinsurance or deductible that a member pays.
Levels 1 & 2 $600 individual /
$1,200 family
$1,000 individual /
$2,000 family
$1,000 individual /
$2,000 family
Level 3 $6,850 individual /
$13,700 family1,5
$6,850 individual /
$13,700 family1,5
None
Level 43 $1,200 individual /
$2,400 family
$1,200 individual /
$2,400 family
$1,200 individual /
$2,400 family

 

1 Level 3 coinsurance does not apply toward the group health insurance program’s OOPL 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 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.

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 1:41:11 PM