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


Local Health Plan
Insurance for Employees
and Retirees
(PO6, PO16)


Breakdown of Your Costs by Plan Design

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

Local Program Options 6 and 16

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

 

 

Local Health Plan

Local Access Health Plan
in-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

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

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

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

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

Plan pays 100%

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

After deductible you pay 10% 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%

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.

Medical Out-of-Pocket Limit (OOPL)

Individual / Family

$1,250 / $2,500

 

Local Health Plan

Local Access Health Plan

Prescription Deductible None

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

1 Must use an in-network pharmacy

 

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 co

 

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 12:01:42 PM