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


Local High Deductible Health Plan
Insurance for Employees
and Retirees
(PO7, PO17)


Breakdown of Your Costs by Plan Design

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

Local Program Options 7 and 17

The table below lists costs for common services for each It's Your Choice plan design option. This is not a complete description of coverage, you can find that in the Certificates of Coverage.

 

Local HDHP

Local Access HDHP
In-Network

Local Access HDHP
Out-of-Network

Annual Deductible
(includes medical and prescription drugs)

$1,500 individual / $3,000 family

The deductible must be met before coverage begins; for family coverage, the full family deductible must be met

The deductible includes prescription drugs and applies to OOPL

$2,000 individual / $4,000 family

The deductible must be met before coverage begins; for family coverage, the full family deductible must be met

The deductible includes prescription drugs and applies to OOPL

Primary Care Physician (PCP) Office Visit Copayment
Includes:

• Internist
• General Physician
• Family Practitioner
• Pediatrician
• Gynecologist / Obstetrician
• Nurse Practitioner
• Physician Assistant
• Chiropractor
• Physical / Occupational / Speech Therapy in an office visit setting.

You pay the full allowed amount of an office visit until deductible is met

After deductible: You pay $15 copay per office visit up to OOPL

Coinsurance will apply to additional services such as lab work, X-rays, etc.

You pay the full allowed amount of an office visit until deductible is met

After deductible: You pay 30% coinsurance up to OOPL

Specialty Office Visit Copayment
Includes:

• Specialty Providers
• Urgent Care
• Vision Exam in an office visit setting.

You pay the full allowed amount of an office visit until deductible is met

After deductible: You pay $25 copay per office visit up to OOPL

Coinsurance will apply to additional services such as lab work, X-rays, etc.

You pay the full allowed amount of an office visit until deductible is met

After deductible: You pay 30% coinsurance up to OOPL

Annual Medical Coinsurance

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Applies to medical services except for office visit or emergency room copays and preventive services*

You pay the full allowed amount of services until deductible is met

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

Applies to medical services except for emergency room copays

Annual Out-of-Pocket Limit (OOPL)
(includes medical and prescription drugs)

$2,500 individual / $5,000 family

For family coverage, you must meet the full family OOPL before your plan pays 100%

$3,800 individual / $7,600 family

For family coverage, you must meet the full family OOPL before your plan pays 100%

Routine, preventive services as required by federal law

Plan pays 100%, not subject to deductible
For details, visit healthcare.gov

Subject to the deductible and coinsurance

Illness/injury related services beyond the office visit copayment (if applicable)

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Applies to medical services except for office visit or emergency room copays

You pay the full allowed amount of services until deductible is met

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

Applies to medical services except for emergency room copays

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

You pay the full allowed amount of services until deductible is met

After deductible: You pay $75 copay per visit, then coinsurance applies to services beyond the copay up to OOPL

You pay the full allowed amount of services until deductible is met

After deductible: You pay $75 copay per visit, then in-network deductible and coinsurance applies to services beyond the copay up to OOPL

Transplants

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

You pay the full allowed amount of services until deductible is met

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

Mental Health/Alcohol & Drug Abuse

Outpatient services: after deductible, you pay $15 copay for primary care office visits. Additional services such as lab
work, assessments, etc., are subject to coinsurance

Inpatient and covered transitional services: after deductible plan pays 90%, you pay 10% coinsurance up to OOPL

All services apply  to the annual OOPL

Outpatient, inpatient and covered transitional services: after deductible plan pays 70%, you pay 30% coinsurance up to OOPL

Hearing aid (per ear)

You pay the full allowed amount of services until deductible is met

After deductible: Every three years:

Adults, you pay 20% coinsurance up to plan paid $1,000 (not to OOPL); dependents younger than age 18, plan pays 90%, you pay 10% coinsurance up to OOPL

You pay the full allowed amount
of services until deductible is met

Every three Years:

After deductible:For dependents younger than age 18, plan pays 70%, you pay 30% coinsurance up to OOPL

Cochlear Implants

You pay the full allowed amount of services until deductible is met

Adults, after deductible, plan pays 80%, you pay 20% coinsurance up to OOPL for device, surgery for implantation, follow-up sessions;

For hospital charge for surgery:

Adults, after deductible plan pays 90%, you pay 10% coinsurance up to OOPL

Dependents under age 18, after deductible, plan pays 90%, you pay 10% coinsurance up to OOPL for all services

You pay the full allowed amount
of services until deductible is met

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

Skilled Nursing Facility (non-custodial care)

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 120 days per benefit period

You pay the full allowed amount
of services until deductible is met

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

Home Health (non-custodial)

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 50 visits per year

Plan may approve an additional 50 visits

You pay the full allowed amount
of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL, 50 visits per plan year

Plan may approve an additional 50 visits

Physical/Speech/Occupational Therapy

You pay the full allowed amount of services until deductible is met

After deductible: You pay $15 copay for office visits. Additional services such as lab
work, X-rays, etc. are subject to coinsurance up to OOPL

50 combined visits per year

Plan may approve an additional 50 visits per therapy type per year

You pay the full allowed amount
of services until deductible is met

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

50 combined visits per plan year

Plan may approve an additional 50 visits per therapy type per year

Durable Medical Equipment

You pay the full allowed amount of services until deductible is met

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

You pay the full allowed amount of services until deductible is met

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

Contact WEA Trust

Referrals

In-network–varies by plan. See plan descriptions and contact your plan

For the Local HDHP, a referral is required for any benefits to be covered out-of-network

Not required

Oral Surgery

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

You pay the full allowed amount of services until deductible is met

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

 

Local HDHP

Local Access HDHP
In-Network

Local Access HDHP
Out-of-Network

Prescription Copay

Level 1

After deductible: $5

Must use in-network Pharmacy
Level 2 After deductible: 20% ($50 max)
Level 3

After deductible: 40% ($150 max)

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

Level 4 Specialty After deductible: $50 copay (Must be filled at Lumicera or UW Specialty Pharmacy)
Preventive Prescriptions Plan pays 100%, regardless of deductible
*Routine, preventive services as required by federal law

 

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 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.

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 after you meet your deductible; 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 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 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: 9/12/2018 7:01:23 AM