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Wisconsin Department of Employee Trust Funds header image It's Your Choice 2019 Local Deductible Health Plan Insurance Program
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2019 It's Your Choice - Local Deductible Health Plan Insurance for Employees and Retirees
Wisconsin Department Of Employee Trust Funds It's Your Choice 2019


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


Breakdown of Your Costs by Plan Design

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

Local Program Options 4 and 14

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 Deductible

Local Access Deductible Plan
In-Network

Local Access Deductible Plan
Out-of-Network

Annual Medical Deductible

$500 individual / $1,000 family

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

Deductible applies to annual out-of-pocket limit (OOPL)

Medical deductible does not apply to prescription drugs

$1,000 individual / $2,000 family

When an individual within a family plan meets the $1,000 deductible, benefits apply as described below

Deductible applies to annual out-of-pocket limit (OOPL)

Medical deductible does not apply to prescription drugs

Annual Medical Coinsurance

After deductible: Plan pays 100% for most services, except for durable medical equipment, certain hearing aids and cochlear implants. See below

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Applies to medical services

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

$4,000 individual $8,000 family (includes deductible)

Routine, preventive services as required by federal law

Plan pays 100%

For details, visit
healthcare.gov

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Illness/injury related services

After deductible: Plan pays 100%

After deductible: Plan pays 70%, you pay 30% coinsurance 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.)

You pay $60 copay per visit

After copay, deductible applies

You pay $75 copay, after copay in-network deductible and 30% coinsurance up to OOPL

Vision Exam

Routine exam: After deductible plan pays 100% for one routine eye exam per year

Illness or injury: After deductible plan pays 100% for adults or children

Routine exam: No benefit

Illness or injury: After deductible plan pays 70% for adults or children; you pay 30% coinsurance up to OOPL

Hearing Exam

After deductible: Plan pays 100%

After deductible: Plan pays 70% only when exam is for illness or disease; you pay 30% coinsurance up to OOPL

Hearing Aid
(per ear)

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

Children: After deductible, plan pays 100%

Every 3 years:
Adults: No benefit

Children: After deductible, plan pays 70%, you pay 30% coinsurance up to OOPL

Cochlear Implants

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

Dependents under age 18: Plan pays 100% for all services

Dependents under age 18: After deductible plan pays 70%, you pay 30% coinsurance up to OOPL for device, surgery, follow-up sessions

Durable Medical Equipment

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

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Physical/Speech/Occupational Therapy

After deductible: 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 70%, you pay 30% coinsurance up 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)

After deductible: Plan pays 100% for 120 days per benefit period

After deductible: Plan pays 70% for 120 days per benefit period; you pay 30% coinsurance up to OOPL

Home Health
(Non-custodial)

After deductible: Plan pays 100% for 50 visits per year. Plan may approve an additional 50 visits

After deductible: Plan pays 70%, you pay 30% 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: After deductible: plan pays 100%

Outpatient, inpatient and covered transitional services: After deductible: Plan pays 70%, you pay 30% member cost up to OOPL

Transplants

After deductible: plan pays 100%

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

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

After deductible: plan pays 100%

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

 

Local Deductible

Local Access Deductible Health Plan
In-Network

Local Access Deductible Health 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 3 “Dispense as Written” or “DAW-1” drugs may cost more.

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 100% by the program. You can find a list here.

A list of fully covered contraceptives can be found 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.
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 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 you pay three copays, or the excess as described in the DAW-1 example, below. 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.

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: 12/14/2018 8:17:59 AM