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

Local Deductible Plan
Insurance for Employees
and Retirees
(PO4, PO14)

Pharmacy Benefits for Retirees with Medicare

If you are a retiree without Medicare, see retiree pharmacy benefits. If you are an active employee (or on COBRA), see active pharmacy benefits.

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

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 Local Deductible Plan
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 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
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.

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 2:41:11 PM