It's Your Choice 2013 - Decision Guide (ET-2128d-13) - ETF

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Comparison of Benefit Options BENEFIT Hearing Aid (per ear) Cochlear Implants Routine Vision Exam Skilled Nursing Facility (non custodial care) Home Health (non custodial) Physical/ Speech/ Occupational Therapy Durable Medical Equipment UNIFORM BENEFITS Every 3 years: Adults, 80%/20%, up to $1,000; dependents younger than 18 years, 100%, maximum does not apply Adults, 80%/20% for device, surgery, follow-up sessions; 100% hospital charge for surgery. Dependents under 18, 100% One per year 120 days per benefit period 50 visits per year; plan may approve an additional 50 50 visits per year; plan may approve an additional 50 80%/20% coinsurance, $500 OOPL STANDARD PLAN (If under Medicare Age) Preferred Provider For dependents younger than 18 years only, every 3 years—deductible Dependents under 18, deductible for device, surgery, follow-up sessions 100% for children under age 5 6 ; illness or disease only, deductible Deductible, as medically necessary, 120 days per benefit period Deductible, 50 visits per plan year; plan may approve an additional 50 Deductible, 50 visits per plan year; plan may approve an additional 50 Deductible Non-Preferred Provider For dependents younger than 18 years only, every 3 years—deductible and coinsurance Dependents under 18, deductible and coinsurance for device, surgery, follow-up sessions No benefit for routine; illness or disease only, deductible and coinsurance Deductible and coinsurance, as medically necessary, 120 days per benefit period Deductible and coinsurance, 50 visits per plan year; plan may approve an additional 50 Deductible, 50 visits per plan year; plan may approve an additional 50 Deductible and coinsurance MEDICARE Plus (and Medicare Part A, B and D 8 ) For dependents younger than 18 years only, every 3 years—100% Dependents under 18, 100% for device, surgery, follow-up sessions No benefit for routine; illness or disease only, 100% 100% 120 days/ benefit period at Medicareapproved facility. At non-Medicareapproved facility, if transferred within 24 hours of hospital release, benefits payable up to 30 days/confinement 100% 100% 100% Footnotes are explained on Page 22. Decision Guide Page 24
Comparison of Benefit Options BENEFIT UNIFORM BENEFITS STANDARD PLAN (If under Medicare Age) Preferred Provider Non-Preferred Provider MEDICARE Plus (and Medicare Part A, B and D 8 ) Hospital Pre-Certification Referrals Treatment for Morbid Obesity Varies by plan In-network varies by plan; out-ofnetwork required. Excluded WPS Medical Management for inpatient stays WPS Medical Management for inpatient stays None required None required Not required Not required Deductible at Center of Excellence in-network provider Oral Surgery 11 procedures 23 procedures— deductible Non-preferred provider deductible and coinsurance outside Center of Excellence provider 23 procedures— deductible and coinsurance 100% for Medicarecovered service 100% Dental Care Varies by plan No benefit No benefit No benefit Drug Copays and OOPL 6 (non-specialty) Specialty Drug Copays and OOPL 6 Preferred Pharmacy Specialty Drug Copays and OOPL 6 Non-Preferred Pharmacy Level 1=$5; 2=$15; 3=$35 7 OOPL $410 individual/$820 family Formulary drugs $15 to OOPL $1,000 individual/$2,000 family; Non-formulary drugs $50, no OOPL Formulary drugs $50 to OOPL $1,000 individual/$2,000 family; Non-formulary drugs $50, no OOPL Level 1=$5; 2=$15; 3=$35 7 OOPL $1,000 individual/$2,000 family Formulary drugs $15 to OOPL $1,000 individual/$2,000 family; Non-formulary drugs $50, no OOPL Not applicable Level 1=$5; 2=$15; 3=$35 7 OOPL $1,000 individual/$2,000 family Not applicable Formulary drugs $50 to OOPL $1,000 individual/$2,000 family; Non-formulary drugs $50, no OOPL Level 1=$5; 2=$15; 3=$35 7 OOPL $410 individual/$820 family Formulary drugs $15 to OOPL $1,000 individual/$2,000 family; Non-formulary drugs $50, no OOPL Formulary drugs $50 to OOPL $1,000 individual/$2,000 family; Non-formulary drugs $50, no OOPL Footnotes are explained on Page 22. Decision Guide Page 25
Page 1 and 2: It’s Your Choice: 2013 Decision G
Page 3 and 4: Table of Contents Choose Wisely....
Page 5 and 6: Choose Wisely Sheboygan Fiesta Hisp
Page 7 and 8: Choose Wisely Standard Plan Benefit
Page 9 and 10: FREQUENTLY ASKED QUESTIONS IT’S Y
Page 11 and 12: Choose Wisely dependents through th
Page 13 and 14: Choose Wisely back of this Guide or
Page 15 and 16: Choose Wisely When you use in-netwo
Page 17 and 18: Choose Your Health Plan radiology (
Page 19 and 20: Local Government Employees and Annu
Page 21 and 22: LOCAL HEALTH PLAN TIERS Choose Your
Page 23 and 24: Choose Your Health Plan HEALTH PLAN
Page 25: Comparison of Benefit Options BENEF
Page 29 and 30: Choose Your Health Plan coordinated
Page 31 and 32: Health Plan Features - At a Glance
Page 33 and 34: Anthem Blue Preferred - Northeast N
Page 35 and 36: Anthem Blue Preferred - Southeast N
Page 37 and 38: Dean Health Plan Inc. (800) 279-130
Page 39 and 40: Group Health Cooperative of South C
Page 41 and 42: Health Tradition Health Plan (877)
Page 43 and 44: Humana - Eastern (800) 4humana [(80
Page 45 and 46: Medical Associates Health Plans (80
Page 47 and 48: MercyCare Health Plans (800) 895-24
Page 49 and 50: Physicians Plus (608) 282-8900 or (
Page 51 and 52: Standard Plan Administered by WPS H
Page 53 and 54: UnitedHealthcare of Wisconsin North
Page 55 and 56: Unity Health Insurance - Community
Page 57 and 58: WEA Trust PPO - East (800) 279-4000
Page 59 and 60: WPS Metro Choice Northwest (800) 63
Page 61 and 62: Choose Quality HEALTH PLAN REPORT C
Page 63 and 64: Quality Composite Rating Chart Unde
Page 65 and 66: CAHPS ® Composite Rating Chart Und
Page 67 and 68: Choose Quality GRIEVANCE AND COMPLA
Page 69 and 70: Choose Quality OTHER QUALITY INFORM
Page 71 and 72: NAVITUS HEALTH SOLUTIONS — Pharm
Page 73 and 74: NAVITUS MedicareRX (PDP)— Pharmac
Page 75 and 76: For Medicare eligible, retired, dis
Page 77 and 78:
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Page 79 and 80:
myETF Benefits System Instructions
Page 81 and 82:
Department of Employee Trust Funds
Page 83 and 84:
ETF Use Only State of Wisconsin Dep
Page 85 and 86:
Applicant Name Social Security Numb
Page 87 and 88:
DUPLICATE APPLICATION FOR YOUR RECO
Page 89 and 90:
DUPLICATE APPLICATION FOR YOUR RECO
Page 91 and 92:
Glossary Coinsurance: Your share of
Page 93 and 94:
Glossary In-network Copayment: A fi
Page 95 and 96:
Glossary Preventive Services: Routi
Page 97 and 98:
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Page 99 and 100:
Health Plan Contact Information Ant
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It's Your Choice 2013 - Decision Guide (ET-2128d-13) - ETF

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