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

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Choose Wisely Eagle River Klondike Days Changes to Dental Coverage For more information, see the Health Plan Description pages in the Choose Your Health Plan section. Network Health Plan Other Information on ETF’s Internet Site Online Help Online Help All plans Increasing the age limit for sealants to 18. Decreasing the allowable frequency of X-rays to: bitewings once a year and full mouth once every five years. The It’s Your Choice: Decision Guide and It’s Your Choice: Reference Guide are available at etf.wi.gov. Any known printing discrepancies will be clarified on this site. Other information is available about insurance programs, including the complete Report Card on health plans. Look for the red envelope to sign up for ETF E-Mail Updates at etf.wi.gov. Are you unsure where to start with the It’s Your Choice: Decision and Reference Guides? ETF has an online tutorial to provide information on changes and services we offer. Find it on etf.wi.gov under the Group Health Insurance menu. Decision Guide Page 6
FREQUENTLY ASKED QUESTIONS IT’S YOUR CHOICE OPEN ENROLLMENT PERIOD The “It’s Your Choice” Open Enrollment period is the annual opportunity for eligible employees and insured annuitants to select one of the many health plans offered by the Wisconsin Public Employers Group Health Insurance Program. Today, there are more than 18 health plans to choose from. The following list contains some of the most common questions about the enrollment period. You can also find information about key terms in the Glossary at the back of this Guide. NEW BENEFITS AND ELIGIBILITY CHANGES 1. What is the It’s Your Choice Open Enrollment period? The It’s Your Choice Open Enrollment period is an opportunity to change plans, change from family to single coverage, enroll if you had previously deferred coverage, change your coverage, or cancel the coverage for your adult dependent child. It is offered only to employees and insured annuitants who are eligible under the Wisconsin Public Employers Group Health Insurance Program. Changes Choose Wisely made become effective January first of the following year. 2. How does the prescription drug benefit work for the Level 4 copay for specialty and certain other medications? Formulary and non-formulary prescription drugs that are classified by Navitus as specialty medications have a Level 4 copayment of $50 when they are filled at a participating network pharmacy. The $50 copayment for formulary specialty drugs counts toward your $1,000/$2,000 Level 4 out-of-pocket limit (OOPL). Copayments for non-formulary specialty drugs do not count toward the Level 4 OOPL. We strongly encourage you to participate in the Navitus SpecialtyRx, specialty pharmacy program. If you have your prescriptions for specialty drugs filled at the preferred participating pharmacy for specialty medications, which is currently Diplomat Specialty Pharmacy, you will have a reduced copayment of $15 for formulary specialty drugs (which also counts toward the Level 4 OOPL). These drugs will be marked with “ESP” on the formulary. This also allows you to take advantage of the additional, personalized services available with SEE THE IT’S YOUR CHOICE: REFERENCE GUIDE FREQUENTLY ASKED QUESTIONS SECTION FOR INFORMATION REGARDING DEPENDENT ELIGIBILITY, FAMILY STATUS CHANGES AND HOW TO USE YOUR BENEFITS. Decision Guide Page 7
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: Choose Wisely Standard Plan Benefit
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 and 26: Comparison of Benefit Options BENEF
Page 27 and 28: 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
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WPS Metro Choice Northwest (800) 63
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Choose Quality HEALTH PLAN REPORT C
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Quality Composite Rating Chart Unde
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CAHPS ® Composite Rating Chart Und
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Choose Quality GRIEVANCE AND COMPLA
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Choose Quality OTHER QUALITY INFORM
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NAVITUS HEALTH SOLUTIONS — Pharm
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NAVITUS MedicareRX (PDP)— Pharmac
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For Medicare eligible, retired, dis
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myETF Benefits System Instructions
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Department of Employee Trust Funds
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ETF Use Only State of Wisconsin Dep
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Applicant Name Social Security Numb
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DUPLICATE APPLICATION FOR YOUR RECO
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DUPLICATE APPLICATION FOR YOUR RECO
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Glossary Coinsurance: Your share of
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Glossary In-network Copayment: A fi
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Glossary Preventive Services: Routi
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Health Plan Contact Information Ant
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