Prescription Drug Benefit/PBM
Program Specifics
The Group Insurance Board (GIB) authorized the Department of Employee
Trust Funds (DETF) to contract with a Pharmacy Benefits Manager
(PBM) to provide pharmacy benefits services to all State of Wisconsin
group health insurance participants effective January 1, 2004. All
participants receive their pharmacy benefits from the PBM, Navitus
Health Solutions (Navitus). Participants receive an identification
(ID) card from Navitus and a separate one from their health insurance
plan.
As part of the new prescription drug benefit, a three-level copayment
structure for pharmacy benefits was implemented on January 1, 2004,
and remains in effect for 2005. It is as follows:
Level 1* Copayment for each formulary prescription drug = $5.00
Level 2** Copayment for each formulary prescription drug = $15.00
Level 3 Copayment for each non-formulary prescription drug = $35.00
*Level 1 consists of preferred generic and certain low cost brand
name drugs.
**Level 2 consists of preferred brand name and certain higher cost
generic drugs.
NOTE: Level 3 copayments do not apply to the out-of-pocket maximum
and must continue to be paid after the annual out-of-pocket maximum
has been met.
Annual Out-of-Pocket Maximum (Applies to Level 1 and Level 2 Prescription
Drugs and Insulin):
$300 per individual or $600 per family for all participants, except:
$1,000 per individual or $2,000 per family for State participants
enrolled in the Standard Plan.
There is no annual out-of-pocket maximum for Wisconsin Public Employer
(WPE) participants enrolled in the Standard Plan or State Maintenance
Plan (SMP).
Some participants do not have an annual out-of-pocket maximum.
Check the Schedule of Benefits on page D-7 in your 2004 It's Your
Choice book for more information.
Navitus Health Solutions
Navitus Health Solutions
5 Innovation Court
Appleton, WI 54912
Phone (toll-free): 1-866-333-2757
www.navitus.com
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