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Wisconsin Department of Employee Trust Funds header image It's Your Choice 2018 Local Traditional Health Plan Insurance Program
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2018 It's Your Choice - Local Traditional Health Plan Insurance for Employees and Retirees
Wisconsin Department Of Employee Trust Funds It's Your Choice 2018


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


Breakdown of Your Costs by Plan Design

It’s Your Choice Local Health Program For Actives and Retirees without Medicare

Local Program Options 2 and 12

This chart compares your medical benefit options. This is not a complete description of coverage, you can find that in the Certificates of Coverage.

 

IYC Local Traditional

IYC Local Access Plan
In-Network

IYC Local Access Plan
Out-of-Network

Annual Medical Deductible

No deductible

$500 individual / $1,000 family

When an individual within a family plan meets the $500 deductible, coinsurance will apply to covered medical services

Medical deductible does not apply to prescription drugs

Annual Medical Coinsurance

Plan pays 100% for most services, except for durable medical equipment, certain hearing aids and cochlear implants

After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL

Annual Medical Maximum
Out-of-Pocket Limit (OOPL)

Only applies to durable medical equipment (see separate OOPL below), certain hearing aids and cochlear implants
$6,850 individual / $13,700 family for federally required essential health benefits

None

Routine, preventive services as required by federal law

Plan pays 100%

For details, visit
healthcare.gov

After deductible plan pays 80%, you pay 20% coinsurance to OOPL

Illness/injury related services

Plan pays 100% After deductible: Plan pays 80%, you pay 20% coinsurance to OOPL

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

You pay $60 copay per visit You pay $75 copay, the in-network deductible applies to services after the copay

Vision Exam

Plan pays 100% for one routine exam per year; plan pays 100% for exams related to illness or injury

Routine exam: No benefit

Illness or injury: After deductible plan pays 80% for adults or children; you pay 20% coinsurance to OOPL

Hearing Exam

Plan pays 100% After deductible: Plan pays 80% only when exam is for illness or disease; you pay 20% coinsurance to OOPL

Hearing Aid
(per ear)

Every 3 years:
Adults: Plan pays 80% up to $1,000 benefit limit, you pay 20% coinsurance for the first $1,000 and the full cost after

Children: Plan pays 100%

Every 3 years:
Adults: No benefit

Children: After deductible, plan pays 80%; you pay 20% coinsurance to OOPL

Cochlear Implants

Adults: Plan pays 80%, you pay 20% coinsurance for device, surgery, follow-up sessions (not to OOPL); plan pays 100% for hospital charge for surgery

Dependents under 18, plan pays 100% for all services

Dependents under 18, After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL for device, surgery, follow-up sessions

Durable Medical Equipment

Plan pays 80%, you pay 20% coinsurance up to $500 OOPL per person After deductible: Plan pays 80%, you pay 20% coinsurance to OOPL

Physical/Speech/Occupational Therapy

Plan pays 100% for a combined 50 visits per year (amongst all therapies); plan may approve an additional 50 visits per therapy type per year After deductible: Plan pays 80% you pay 20% coinsurance to OOPL for a combined 50 visits per year (amongst all therapies); plan may approve an additional 50 visits per therapy type per year

Skilled Nursing Facility
(non-custodial care)

Plan pays 100% for 120 days per benefit period After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL for 120 days per benefit period

Home Health
(Non-custodial)

Plan pays 100% for 50 visits per year

Plan may approve an additional 50 visits

After deductible: Plan pays 80% and you pay 20% coinsurance up to OOPL for 50 visits per plan year

Plan may approve an additional 50 visits

Mental Health/Alcohol & Drug Abuse

Outpatient, inpatient and covered transitional services. Plan pays 100%

Outpatient, inpatient and covered transitional services. After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL.

Transplants

Plan pays 100%: Includes bone marrow, parathyroid, musculoskeletal, corneal, kidney, heart, liver, kidney with pancreas, heart with lung, and lung

After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL: Includes bone marrow, parathyroid, musculoskeletal, corneal, kidney, with pancreas, heart with lung, and lung

Precertification for hospitalizations, high-tech radiology and low back surgery

Varies by plan

See plan descriptions and contact your plan

Varies by plan

See plan descriptions and contact your plan

Referrals

In-network varies by plan

See plan descriptions and contact your plan

Out-of-network: Referral is required

Not required

Treatment for morbid obesity

Excluded

Excluded

Oral Surgery

Plan pays 100% for 11 procedures

After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL for 11 procedures

 

IYC Local Traditional

IYC Local Access Plan
In-Network

IYC Local Access Plan
Out-of-Network

Prescription Deductible None Must use in-network Pharmacy

Prescription Copay
Level 1

 

$5

Level 2
20% ($50 max)
Level 3
40% ($150 max)
Level 4 Specialty $50 copay
(Must be filled at Lumicera or UW Specialty Pharmacies)
Preventive Plan pays: 100%, regardless of deductible

Prescription Out-of-Pocket Limit

Levels 1 & 2 - Individual / Family

 

$600 / $1,200

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 cover

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: 11/13/2017 10:22:57 AM
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