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Wisconsin Department of Employee Trust Funds header image It's Your Choice 2019 State of Wisconsin Group Health Insurance Program
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2019 It's Your Choice - State of Wisconsin Group Health Insurance for Employees and Retirees

Wisconsin Department Of Employee Trust FundsIt's Your Choice 2019


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

The table below lists costs for common services for each It's Your Choice plan design option. Your Certificate of Coverage details all of your benefits.

 

IYC Health Plan

Access Plan
In-Network

Access Plan
Out-of-Network

HDHP

Access HDHP

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

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
Does not apply to Rx

$2,000 / $4,000

Does not apply to Rx

$2,500 / $5,000
Combined medical & Rx

Families: Must meet full family OOPL before your plan pays 100%

$3,800 / $7,600
Combined medical & Rx

Families: Must meet full family OOPL before your plan pays 100%

 

Health Plan

Access Plan

Access Plan
Out-of-Network

HDHP

Access HDHP

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)

Level 3 “Dispense as Written” or “DAW-1” drugs may cost more.

After deductible: 40% ($150 max)

Level 3 “Dispense as Written” or “DAW-1” drugs may cost more.

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.

A list of fully covered contraceptives can be found here.

“First Dollar” preventive drugs identified by the ACA are subject to copay/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.

These lists may change at any time. You can find the most up-to-date lists here.

You can find a list of the current formulary here. You can also log into Navi-Gate® for members through this page to search for your prescription drugs on 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. Learn more about drugs requiring prior authorization here.

Diabetic supplies and glucometers are covered; you will pay 20% coinsurance as long as you get your supplies from an in-network supplier. Contact Navitus Customer Care if you need help finding one.

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 works with Navitus to provide mail order prescription drugs.. 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. Medicare participants have some additional pharmacy options.

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.

This does not apply to retirees with Medicare

Some doctors write prescriptions as “DAW-1,” or “dispense as written.” This means the pharmacist will fill the brand name drug as written and will not substitute an available generic equivalent.

Starting in 2019, you will pay more for “DAW-1” brand name level 3 drugs unless you cannot take the generic equivalent due to a medical need. If you have medical need, your doctor must submit an FDA MedWatch form to Navitus for the prescription. Have your doctor contact Navitus for the form.

The FDA MedWatch form must be submitted the first time you are prescribed the medication. Under normal circumstances, the form will be processed within 72 hours. For urgent/emergent situations, the form will be processed within 24 hours. After the form is submitted, it will stay on file with Navitus. Your doctor will not need to resubmit the form.

Without the form, you will pay the 40% coinsurance plus the cost difference between the brand name drug and its generic equivalent.

 

Example 1: Level 3 "DAW-1", No Medical Need for Brand Name Drug

Your doctor prescribes you BrandNameStatin and marks it as “DAW-1”. You do not have a medical need so your doctor does not submit the FDA MedWatch form

30-Day Supply Costs

Your Costs with Insurance

  • BrandNameStatin: $1,250
  • Generic equivalent: $5

Cost Before Insurance:

  • BrandNameStatin: $2,000
  • Generic equivalent: $900
BrandNameStatin Cost Calculation

$2,000 x 40% = $800 $150
You pay 40% of the original drug price. There is a limit of $150

$2,000 - $900 = $1,100
You also pay the cost difference between the brand name drug and the generic equivalent

$150 + $1,100 = $1,250

When having a brand name drug is not medically necessary, you can save money by getting the generic. In this example you’d save $1,245 each time you fill your prescription.

Example 2: Level 3 "DAW-1", Medical Need for Brand Name Drug

Your doctor prescribes you BrandNameStatin and marks it as “DAW-1”. The brand name drug is medically necessary because you are allergic to an ingredient in the generic equivalent. Your doctor submits the FDA MedWatch form to Navitus.

30-Day Supply Costs

Your Costs with Insurance

  • BrandNameStatin: $150

Cost Before Insurance:

  • BrandNameStatin: $2,000
BrandNameStatin Cost Calculation

$2,000 x 40% = $800 $150
You pay 40% of the original drug price. $800 is higher than the max, you are only responsible for $150.

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: 9/12/2018 7:01:19 AM