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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)


Important Changes for 2019

View as an eLearning

You can re-enroll in health insurance through ETF if you meet these 3 requirements:

  1. You are a WRS member who retired from a local employer
  2. You were covered by the Group Health Insurance Program on your retirement date
  3. Your former employer still participates in the Group Health Insurance Program

Previously, if you canceled your coverage, you could never re-enroll in the program.

Robin with HealthPartners

HealthPartners has added a new health plan option with coverage in northeast Wisconsin. The new network features, but is not limited to, the following providers:

  • Aurora Health Care
  • BayCare Clinic
  • Bellin Health
  • Dickinson County Healthcare System (DCH System)
  • Holy Family Memorial
  • ThedaCare

Find more information here.

It’s Your Choice Medicare Advantage with UnitedHealthcare®

New option for Medicare-enrolled retirees and their Medicare-enrolled dependents. The plan offers Uniform Benefits and a nationwide network. Find more information here.

State Maintenance Plan (SMP)

SMP is no longer available in Iron and Price counties.

SMP will be newly available in Buffalo, Marinette, Pepin, Pierce, Polk, Shawano, St. Croix, Waupaca, Waushara, and Wood counties.

Make sure your providers are in-network for 2019 or select another plan.

Telehealth

Telehealth services will be covered 100%.

Gender Identity Services

The exclusion related to benefits or services based on gender identity is removed for 2019.

Home Sleep Studies

Coverage for medically necessary sleep studies at home.

Contact Lenses for Keratoconus Treatment

Coverage for one set of medically necessary hard contact lenses if being treated for keratoconus. Consider supplemental vision coverage for additional sets.

Tooth Extractions

Coverage for extraction (removal) of erupted teeth (above the gum line) will be covered by the Uniform Dental Benefit instead of the medical benefit.Your employer may, or may not, offer the Uniform Dental Benefit through ETF. This service may be covered by other dental insurance you may have.

Transplants

Transplant coverage language has been simplified to defer to clinical teams to make decisions on appropriateness.

Skin Tags

Skin tag removal is excluded.

Prescription Foot Orthotics

Coverage for only one orthotic per foot, per year.

Increased Cost Sharing for Brand Name Level 3 Drugs

This change 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 a medical need, your doctor must submit a one-time 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. See the examples below for more explanation.

 

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.

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: 9/11/2018 1:29:19 PM