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Wisconsin Department of Employee Trust Funds header image It's Your Choice 2018 State of Wisconsin Group Health Insurance Program
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2018 It's Your Choice - State of Wisconsin Group Health Insurance for Employees and Retirees

Wisconsin Department Of Employee Trust FundsIt's Your Choice 2018


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

Breakdown of Your Costs by Plan Design

Active State Employees and Retirees without Medicare

Your Certificate of Coverage details all of your benefits.

 

IYC Health Plan

IYC Access Health Plan
in-Network

IYC Access Plan Out-of-Network

IYC HDHP

IYC Access HDHP

IYC Access HDHP
Out-of-Network

Annual Medical Deductible
Individual / Family

Counts toward out-of-pocket limit (OOPL)

$250 / $500

Medical deductible does not apply to office visit copays, preventive services or prescription drugs

After an individual within a family plan meets the $250 deductible, benefits apply as described below

$500 / $1,000

Medical deductible does not apply to
office visit copays, preventive services or prescription drugs

After an individual within a family plan
meets the $500 deductible, benefits apply as described below

$1,500 / $3,000

Must be met before coverage begins
Families: Must meet full family deductible


$2,000 / $4,000

Must be met before coverage begins

Families: Must meet full family deductible
Combined medical & Rx

Primary Care Office Visit
Additional services such as lab work, X-rays, etc., count toward the deductible and coinsurance

Includes:
• Internist
• General Physician
• Family Practitioner
• Pediatrician
• Gynecologist / Obstetrician
• Nurse Practitioner
• Physician Assistant
• Chiropractor
• Physical / Occupational / Speech Therapy in an office visit setting


$15 copay per visit up to OOPL

Does not count toward deductible

After deductible: You pay 30% up to OOPL

You pay 100% until deductible is met

After deductible: $15 copay per visit up to OOPL

After deductible: You pay 30% up to OOPL
Specialty Office Visit
Additional services such as lab work, X-rays, etc., count toward the deductible and coinsurance

Includes:
• Specialty Providers
• Urgent Care
• Vision Exam in an office visit setting


$25 copay per visit up to OOPL

Does not count toward deductible

After deductible: You pay 30% up to OOPL

You pay 100% until deductible is met

After deductible: $25 copay per visit up to OOPL

After deductible: You pay 30% up to OOPL

Annual Medical Coinsurance
Applies to medical services except for office visit or emergency room copayments and preventive services

After deductible you pay 10% up to OOPL

After deductible: You pay 30% up to OOPL

After deductible you pay 10% up to OOPL

After deductible: You pay 30% up to OOPL

Preventive Services
See healthcare.gov/preventive-care-benefits

Plan pays 100%

You pay deductible, copays and/or coinsurance

Plan pays 100%

You pay deductible, copays and/or coinsurance

Transplants
Heart, liver, kidney with pancreas, heart with lung, lung

After deductible you pay 10% up to OOPL

After deductible: You pay 30% up to OOPL After deductible you pay 10% up to OOPL After deductible: You pay 30% up to OOPL

Mental Health/Alcohol and Drug Abuse

Paid until OOPL is met

Additional services such as lab work, assessments, etc., are subject to deductible and coinsurance

Outpatient services: $15 copay per visit

Inpatient & covered transitional services: after deductible, you pay 10%

After deductible: You pay 30% up to OOPL

Outpatient services: $15 copay per visit

Inpatient & covered transitional services: after deductible, you pay 10%

After deductible: You pay 30% up to OOPL

Emergency Room
Copay Waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer.

$75 copay per visit

Copay counts toward OOPL. Deductible and coinsurance may apply to services beyond the copay, up to OOPL.

$75 copay per visit

Copay counts toward in-network OOPL. In-network deductible and coinsurance may apply to services beyond the copay, up to OOPL.

You pay 100% until deductible met

After deductible: $75 copay per visit

Copay counts toward OOPL. Deductible and coinsurance may apply to services beyond the copay, up to OOPL.

After in-network deductible: $75 copay per visit
Copay counts toward in-network OOPL. In-network deductible and coinsurance may apply to services beyond the copay, up to OOPL.

Medical Out-of-Pocket Limit (OOPL)

Individual / Family

$1,250 / $2,500

$2,000 / $4,000

Does not apply to Rx

$2,500 / $5,000
Families: Must meet full family OOPL before your plan pays 100%

$3,800 / $7,600

Combined medical & Rx
 

IYC Health Plan

IYC Access Health Plan

IYC Access Plan
Out-of-Network

IYC HDHP

IYC Access HDHP

IYC Access HDHP
Out-of-Network

Prescription Deductible

None

Must use in-network Pharmacy Included in medical deductible Must be met before coverage begins Must use in-network Pharmacy

Prescription Copay

Level 1

$5

After deductible: $5

Level 2 20% ($50 max) After deductible: 20% ($50 max)
Level 3 40% ($150 max) After deductible: 40% ($150 max)
Level 4 Specialty $50 copay (Must fill at specialty pharmacy) After deductible: $50 copay (Must fill at specialty pharmacy)
Preventive Plan pays 100%, regardless of deductible Plan pays 100%, regardless of deductible

Prescription Out-of-Pocket Limit

Levels 1 & 2 - Individual / Family

 

$600 / $1,200

Included in Medical OOPL

Level 3 - Individual / Family $6,850 / $13,700
Level 4 - Individual / Family $1,200 / $2,400

Additional Prescription Drug Benefit Info:

“Zero Dollar” preventive drugs identified by the Affordable Care Act (ACA) are paid for by the program even if the deductible has not been met. You can find a list here.

“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. You can find a list here.

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.

Some prescription drugs require a prior authorization for it to be covered by the program. 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 supplies and glucometers are covered; you will pay 20% coinsurance. If you are a High Deductible Health Plan participant, you will need to meet your deductible first.
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 the Navitus website or by calling Navitus Customer Care.
Serve You is the new mail order vendor. 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, Serve You website or by calling Navitus Customer Care.
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.
(Level 4 Self-Injectables and Specialty Medications)
If you are taking a specialty medication, the Navitus SpecialtyRx Program is offered through both Lumicera Specialty Pharmacy and the UW Specialty Pharmacy for non-Medicare participants. Specialty medications are marked with “ESP” in the formulary.  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.
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 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: 3/2/2018 12:01:01 PM